Provider Demographics
NPI:1053470542
Name:FIFE, SALLY M (OD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:FIFE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 9TH ST
Mailing Address - Street 2:P O BOX 595
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2751
Mailing Address - Country:US
Mailing Address - Phone:270-827-8681
Mailing Address - Fax:270-826-7687
Practice Address - Street 1:300 9TH ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2751
Practice Address - Country:US
Practice Address - Phone:270-827-8681
Practice Address - Fax:270-826-7687
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1017DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100121660Medicaid
KY0675230001OtherPALMETTO
KY000000190215OtherANTHEM
KYT54732Medicare UPIN
KY000000190215OtherANTHEM