Basic Information
| Provider Information | |||||||||
| NPI: | 1386770626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERBY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 263 | ||||||||
| Address2: | 1001 MONROE ROAD | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450360263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139342020 | ||||||||
| FaxNumber: | 5139342028 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MONROE RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450361414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139342020 | ||||||||
| FaxNumber: | 5139342028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4756 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 020870 | 01 | OH | ANTHEM | OTHER | 6574 | 01 | OH | HUMANA | OTHER | 2053414 | 05 | OH | MEDICAID | 281777 | 01 | OH | PREFERRED EYE CARE PROVID | OTHER | 0005188584 | 01 | OH | AETNA | OTHER |