Basic Information
| Provider Information | |||||||||
| NPI: | 1811216971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUHA OPTOMETRIC GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3097 CAVERSHAM PARK LN | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405098501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594920162 | ||||||||
| FaxNumber: | 6067842124 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 OSBOURNE WAY | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403249636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028639777 | ||||||||
| FaxNumber: | 5028671226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | MUHA | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 8594920162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1590DT | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 7100017080 | 05 | KY | MEDICAID |