Provider Demographics
NPI:1790858538
Name:ROBERT MARSHALL THARP, JR, OD, INC
Entity Type:Organization
Organization Name:ROBERT MARSHALL THARP, JR, OD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:THARP
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:601-991-9723
Mailing Address - Street 1:6351 INTERSTATE 55 NORTH
Mailing Address - Street 2:STE. 115-B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:601-991-9723
Mailing Address - Fax:601-991-9745
Practice Address - Street 1:6351 INTERSTATE 55 NORTH
Practice Address - Street 2:STE. 115-B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-991-9723
Practice Address - Fax:601-991-9745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014792Medicaid
MS02311Medicare ID - Type Unspecified