Healthcare Provider Details

I. General information

NPI: 1700890001
Provider Name (Legal Business Name): KY DOCTORS OF OPTOMETRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 OUTER LOOP
LOUISVILLE KY
40219-3970
US

IV. Provider business mailing address

175 E HOUSTON ST
SAN ANTONIO TX
78205-2255
US

V. Phone/Fax

Practice location:
  • Phone: 502-966-2020
  • Fax: 502-966-2099
Mailing address:
  • Phone: 210-524-6803
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: GRANT RUBESH
Title or Position: OWNER
Credential: OD
Phone: 812-786-9021