Provider Demographics
NPI:1972675577
Name:OPTOMETRIC CLINIC, PA
Entity Type:Organization
Organization Name:OPTOMETRIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-545-2020
Mailing Address - Street 1:600 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3834
Mailing Address - Country:US
Mailing Address - Phone:601-545-2020
Mailing Address - Fax:601-583-0120
Practice Address - Street 1:600 W PINE ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3834
Practice Address - Country:US
Practice Address - Phone:601-545-2020
Practice Address - Fax:601-583-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS508152W00000X
MS550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087064Medicaid
MS00880007Medicaid
MS540017775OtherRRMEDICARE
MS410012873OtherRR MEDICARE
MS540017775OtherRRMEDICARE
MS410000038Medicare ID - Type UnspecifiedLISA HERRINGTON, OD
MST93631Medicare UPIN
MS410012873OtherRR MEDICARE
MSC00584Medicare PIN
MST93630Medicare UPIN