=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235241381
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNNY RAY DUKES OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 11/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 N MAIN ST
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29720-2188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-285-8433
-----------------------------------------------------
Fax | 803-285-5071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 929 N MAIN ST
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29720-2188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-285-8433
-----------------------------------------------------
Fax | 803-285-5071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 767
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------