Provider Demographics
NPI:1932224748
Name:EYECARE PROFESSIONALS PA
Entity Type:Organization
Organization Name:EYECARE PROFESSIONALS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JEFFREYS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:601-366-1085
Mailing Address - Street 1:1501 LAKELAND DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4848
Mailing Address - Country:US
Mailing Address - Phone:601-366-1085
Mailing Address - Fax:601-366-5186
Practice Address - Street 1:1501 LAKELAND DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4848
Practice Address - Country:US
Practice Address - Phone:601-366-1085
Practice Address - Fax:601-366-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14957207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016216Medicaid
MS09016216Medicaid
180000283Medicare PIN
MSG90204Medicare UPIN