Provider Demographics
NPI:1598179715
Name:PROVENCE-PERRY, MEGAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:
Last Name:PROVENCE-PERRY
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 1:1600 W SUNSET AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5136
Mailing Address - Country:US
Mailing Address - Phone:479-756-1234
Mailing Address - Fax:
Practice Address - Street 1:1600 W SUNSET AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-5136
Practice Address - Country:US
Practice Address - Phone:479-756-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist