Healthcare Provider Details

I. General information

NPI: 1326016601
Provider Name (Legal Business Name): CATHY L PHILLIPS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHY PHILLIPS PORTER

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W OSAGE ST
PACIFIC MO
63069-1331
US

IV. Provider business mailing address

40 E NORTH ST
EUREKA MO
63025-1205
US

V. Phone/Fax

Practice location:
  • Phone: 636-271-4500
  • Fax: 636-271-6940
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-938-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03068
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT03068
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: