Provider Demographics
NPI:1447335807
Name:PAYNE, DOUGLAS WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:PAYNE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071
Mailing Address - Country:US
Mailing Address - Phone:270-753-5507
Mailing Address - Fax:270-753-5504
Practice Address - Street 1:809 ARCADIA CIR
Practice Address - Street 2:SUITE A
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1563
Practice Address - Country:US
Practice Address - Phone:270-753-5507
Practice Address - Fax:270-753-5504
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1489DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000982Medicaid
KY9371301Medicare ID - Type Unspecified
U82670Medicare UPIN