Provider Demographics
NPI:1811177843
Name:HALL, TODD (OD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:HALL
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 1:814 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2825
Mailing Address - Country:US
Mailing Address - Phone:662-453-5400
Mailing Address - Fax:662-453-5726
Practice Address - Street 1:814 W PARK AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2825
Practice Address - Country:US
Practice Address - Phone:662-453-5400
Practice Address - Fax:662-453-5726
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880003Medicaid
MS00880003Medicaid
MS410000080Medicare PIN
MSU25357Medicare UPIN