Healthcare Provider Details

I. General information

NPI: 1275292773
Provider Name (Legal Business Name): SUNDERMAN DOWDALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 ALEXANDRIA PIKE
FORT THOMAS KY
41075-1729
US

IV. Provider business mailing address

92 ALEXANDRIA PIKE
FORT THOMAS KY
41075-1729
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-2000
  • Fax:
Mailing address:
  • Phone: 859-781-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State

VIII. Authorized Official

Name: TYLER DOWDALL
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 859-781-2000