Provider Demographics
NPI:1194014118
Name:ODOMS EYE CARE, PLLC
Entity Type:Organization
Organization Name:ODOMS EYE CARE, PLLC
Other - Org Name:ODOMS EYE CARE/OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELLIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-977-0835
Mailing Address - Street 1:1461 CANTON MART RD STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5413
Mailing Address - Country:US
Mailing Address - Phone:601-977-0835
Mailing Address - Fax:601-977-0689
Practice Address - Street 1:1461 CANTON MART RD STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5413
Practice Address - Country:US
Practice Address - Phone:601-977-0835
Practice Address - Fax:601-977-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS677152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02735526Medicaid
MS02735526Medicaid