Provider Demographics
NPI:1467581066
Name:PRY, DONNA JO (OD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:JO
Last Name:PRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 W PARK MALL
Mailing Address - Street 2:JC PENNEY OPTICAL
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6341
Mailing Address - Country:US
Mailing Address - Phone:573-335-1930
Mailing Address - Fax:573-334-9493
Practice Address - Street 1:200 W PARK MALL
Practice Address - Street 2:JC PENNEY OPTICAL
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6341
Practice Address - Country:US
Practice Address - Phone:573-335-1930
Practice Address - Fax:573-334-9493
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003025361152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO216516OtherEYEMED PROVIDER