Provider Demographics
NPI:1255472502
Name:GRIFFIN, MARY LORD (OD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LORD
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ALLISON
Other - Last Name:LORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:239 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-4234
Mailing Address - Country:US
Mailing Address - Phone:662-332-0163
Mailing Address - Fax:662-378-3394
Practice Address - Street 1:239 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4234
Practice Address - Country:US
Practice Address - Phone:662-332-0163
Practice Address - Fax:662-378-3394
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS772152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09474826Medicaid