Provider Demographics
NPI:1770505414
Name:HOLLIMON, JERRY AUBREY (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:AUBREY
Last Name:HOLLIMON
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 1:110 W ROBERT ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-3227
Mailing Address - Country:US
Mailing Address - Phone:985-345-0607
Mailing Address - Fax:985-345-0490
Practice Address - Street 1:110 W ROBERT ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-3227
Practice Address - Country:US
Practice Address - Phone:985-345-0607
Practice Address - Fax:985-345-0490
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA739-066T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1131440Medicaid
LA47719Medicare ID - Type Unspecified
LA1131440Medicaid