Provider Demographics
NPI:1922409028
Name:GRADY M. CLARK JR., O.D.P.A.
Entity Type:Organization
Organization Name:GRADY M. CLARK JR., O.D.P.A.
Other - Org Name:EYETECH EYECARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-693-2020
Mailing Address - Street 1:2112 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-6158
Mailing Address - Country:US
Mailing Address - Phone:601-693-2020
Mailing Address - Fax:601-693-2690
Practice Address - Street 1:2112 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-6158
Practice Address - Country:US
Practice Address - Phone:601-693-2020
Practice Address - Fax:601-693-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-08
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS362957Medicare PIN
MS410000039Medicare PIN