Provider Demographics
NPI:1740343276
Name:MAYDEW THIBAULT OPTOMETRY LLC
Entity type:Organization
Organization Name:MAYDEW THIBAULT OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:O
Authorized Official - Last Name:MAYDEW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:620-672-5934
Mailing Address - Street 1:PO BOX 1024
Mailing Address - Street 2:216 S. OAK ST.
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-1024
Mailing Address - Country:US
Mailing Address - Phone:620-672-5934
Mailing Address - Fax:620-672-3550
Practice Address - Street 1:216 S OAK ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2721
Practice Address - Country:US
Practice Address - Phone:620-672-5934
Practice Address - Fax:620-672-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200966630AMedicaid
KS200966630AMedicaid
650512Medicare ID - Type Unspecified