Provider Demographics
NPI:1073622106
Name:HUBBARD, BENJAMIN T JR (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:T
Last Name:HUBBARD
Suffix:JR
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 1:260 POWER DR
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-3010
Mailing Address - Country:US
Mailing Address - Phone:662-563-5533
Mailing Address - Fax:662-563-0777
Practice Address - Street 1:260 POWER DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606
Practice Address - Country:US
Practice Address - Phone:662-563-5533
Practice Address - Fax:662-563-0777
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880063Medicaid
410000125Medicare PIN
MSU56589Medicare UPIN
3915080001Medicare NSC