Provider Demographics
NPI:1053385476
Name:GADDIE, IAN BEN (OD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:BEN
Last Name:GADDIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 SCHULER LN
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9501
Mailing Address - Country:US
Mailing Address - Phone:502-429-5544
Mailing Address - Fax:
Practice Address - Street 1:7635 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5409
Practice Address - Country:US
Practice Address - Phone:502-423-8500
Practice Address - Fax:502-339-0571
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1374DT152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013746Medicaid
KY000000075138OtherANTHEM
U66679Medicare UPIN
KY000000075138OtherANTHEM
KY77013746Medicaid
410039862Medicare PIN