Basic Information
| Provider Information | |||||||||
| NPI: | 1386694461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YACKEY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1945 CEI DR | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452423311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139845133 | ||||||||
| FaxNumber: | 5134690677 | ||||||||
| Practice Location | |||||||||
| Address1: | 1945 CEI DR | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452423311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139845133 | ||||||||
| FaxNumber: | 5134690677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/31/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5517T2429 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | P00409747 | 01 | OH | RAILROAD MEDICARE | OTHER | 200830720 | 05 | IN | MEDICAID | 2530701 | 05 | OH | MEDICAID | 000000344873 | 01 | BCBS FACET | OTHER | 7100062090 | 05 | KY | MEDICAID |