Provider Demographics
NPI:1558410035
Name:CAGLE, LAURIE WADE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:WADE
Last Name:CAGLE
Suffix:
Gender:F
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 519
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-0519
Mailing Address - Country:US
Mailing Address - Phone:662-862-9741
Mailing Address - Fax:662-862-3584
Practice Address - Street 1:301 HOSPITAL RD.
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-0519
Practice Address - Country:US
Practice Address - Phone:662-862-9741
Practice Address - Fax:662-862-3584
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS740152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00834230Medicaid
MSV09132Medicare UPIN
MS0767960001Medicare NSC
MS410000357Medicare PIN