Provider Demographics
NPI:1922199751
Name:CLEMENTS MATNEY, CASSANDRA LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:LEIGH
Last Name:CLEMENTS MATNEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CASSANDRA
Other - Middle Name:LEIGH
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 2887
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2887
Mailing Address - Country:US
Mailing Address - Phone:601-482-2020
Mailing Address - Fax:601-693-1847
Practice Address - Street 1:910 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5017
Practice Address - Country:US
Practice Address - Phone:601-482-2020
Practice Address - Fax:601-693-1847
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880188Medicaid
MC2384802OtherUS DEPT OF JUSTICE
MS00880188Medicaid
MS302I418641Medicare PIN
MS410000277Medicare ID - Type UnspecifiedPROVIDER NUMBER