Provider Demographics
NPI:1952604308
Name:GULLEY VISION CLINIC, P.A.
Entity type:Organization
Organization Name:GULLEY VISION CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-375-8271
Mailing Address - Street 1:404 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72201-3702
Mailing Address - Country:US
Mailing Address - Phone:501-375-8271
Mailing Address - Fax:501-375-8272
Practice Address - Street 1:404 LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-3702
Practice Address - Country:US
Practice Address - Phone:501-375-8271
Practice Address - Fax:501-375-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2075152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104316722Medicaid
AR47930OtherMEDICARE PROVIDER NUMBER
AR47930OtherMEDICARE PROVIDER NUMBER
ART20143Medicare UPIN