Provider Demographics
NPI:1144422577
Name:OPTICAL 2000
Entity Type:Organization
Organization Name:OPTICAL 2000
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PANKEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-924-4444
Mailing Address - Street 1:815 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5252
Mailing Address - Country:US
Mailing Address - Phone:601-924-4444
Mailing Address - Fax:601-924-4100
Practice Address - Street 1:815 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5252
Practice Address - Country:US
Practice Address - Phone:601-924-4444
Practice Address - Fax:601-924-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00748152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014038Medicaid
MSC02031Medicare ID - Type Unspecified
MS09014038Medicaid