Provider Demographics
NPI:1417950262
Name:MOTHERSHED, FRED H (OD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:H
Last Name:MOTHERSHED
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3353 N GLOSTER ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-9735
Mailing Address - Country:US
Mailing Address - Phone:662-844-3555
Mailing Address - Fax:662-840-5614
Practice Address - Street 1:3353 N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9735
Practice Address - Country:US
Practice Address - Phone:662-844-3555
Practice Address - Fax:662-840-5614
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS451152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0880222Medicaid
MS410000264Medicare PIN
MS0880222Medicaid