Provider Demographics
NPI:1699843763
Name:MINOR, JEFFREY C (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
Last Name:MINOR
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 1:5 RIVER BEND PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7618
Mailing Address - Country:US
Mailing Address - Phone:601-932-2292
Mailing Address - Fax:601-932-2282
Practice Address - Street 1:5 RIVER BEND PL
Practice Address - Street 2:SUITE B
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7618
Practice Address - Country:US
Practice Address - Phone:601-932-2292
Practice Address - Fax:601-932-2282
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T20750Medicare UPIN