Provider Demographics
NPI:1407552219
Name:MIDSOUTH VISION SERVICE
Entity Type:Organization
Organization Name:MIDSOUTH VISION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-423-7619
Mailing Address - Street 1:8 COUNTY ROAD 197
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-8148
Mailing Address - Country:US
Mailing Address - Phone:662-423-7619
Mailing Address - Fax:662-423-2849
Practice Address - Street 1:8 COUNTY ROAD 197
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-8148
Practice Address - Country:US
Practice Address - Phone:662-423-7619
Practice Address - Fax:662-423-2849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-02
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty