Basic Information
Provider Information | |||||||||
NPI: | 1912954983 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUNCAN | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 509 | ||||||||
Address2: |   | ||||||||
City: | HUMBOLDT | ||||||||
State: | TN | ||||||||
PostalCode: | 383430509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316683018 | ||||||||
FaxNumber: | 7316689158 | ||||||||
Practice Location | |||||||||
Address1: | 1000A VANN DR | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383056001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316683018 | ||||||||
FaxNumber: | 7316689158 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 08/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD1592 | TN | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 3943183 | 05 | TN |   | MEDICAID | 4105782 | 01 | TN | BLUE CROSS BLUE SHEILD | OTHER | 4239243 | 01 |   | CIGNA HEALTHCARE | OTHER | 5466560004 | 01 | TN | MEDICARE DMEPOS | OTHER | 6414 | 01 | TN | TLC MEMPHIS MANAGED CARE | OTHER |