Provider Demographics
NPI:1831276278
Name:CLARK, GRADY MIMS JR (OD)
Entity type:Individual
Prefix:DR
First Name:GRADY
Middle Name:MIMS
Last Name:CLARK
Suffix:JR
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 1:2112 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS457152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087865Medicaid
MS00087865Medicaid
MS410000039Medicare ID - Type Unspecified
MS0832730001Medicare NSC