Provider Demographics
NPI:1225024862
Name:RAGAN, KIMBERLY J (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:J
Last Name:RAGAN
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:PO BOX 2150
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-2150
Mailing Address - Country:US
Mailing Address - Phone:601-853-7640
Mailing Address - Fax:601-853-7614
Practice Address - Street 1:127 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7595
Practice Address - Country:US
Practice Address - Phone:601-853-7640
Practice Address - Fax:601-853-7614
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS727152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04473866Medicaid
MS04473866Medicaid
MS410000320Medicare PIN