Provider Demographics
NPI:1740413616
Name:MCCUBBIN, MARY GRACE (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:MCCUBBIN
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 1:9186 OREGON RD
Mailing Address - Street 2:
Mailing Address - City:LASCASSAS
Mailing Address - State:TN
Mailing Address - Zip Code:37085-4430
Mailing Address - Country:US
Mailing Address - Phone:615-273-2330
Mailing Address - Fax:
Practice Address - Street 1:1764 GALLATIN PIKE N
Practice Address - Street 2:PEARLE VISION
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2122
Practice Address - Country:US
Practice Address - Phone:615-865-8412
Practice Address - Fax:615-865-8470
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000002902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist