Basic Information
| Provider Information | |||||||||
| NPI: | 1295177152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRAVIS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1748 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420012706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704439955 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1748 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420012706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704439955 | ||||||||
| FaxNumber: | 2704421469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2013 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2001-IOD1 | WV | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2138DT | KY | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.