Provider Demographics
NPI:1679505507
Name:MCCLOUD, JASON H (OD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:H
Last Name:MCCLOUD
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 1:107 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1301
Mailing Address - Country:US
Mailing Address - Phone:606-474-5149
Mailing Address - Fax:606-474-0648
Practice Address - Street 1:107 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1301
Practice Address - Country:US
Practice Address - Phone:606-474-5149
Practice Address - Fax:606-474-0648
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1585DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000859Medicaid
KYU96210Medicare UPIN
KY0798701Medicare ID - Type Unspecified