Provider Demographics
NPI:1518021872
Name:POWELL, GEORGE A (OD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name:POWELL
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:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-0717
Mailing Address - Country:US
Mailing Address - Phone:662-456-2020
Mailing Address - Fax:662-456-3494
Practice Address - Street 1:812 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-1203
Practice Address - Country:US
Practice Address - Phone:662-456-2020
Practice Address - Fax:662-456-3494
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880035Medicaid
MS00880035Medicaid