Provider Demographics
NPI:1447300629
Name:MCBRIDE LLC, JERRY (OD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:MCBRIDE LLC
Suffix:
Gender:M
Credentials:OD
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:MCBRIDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:301 HOSPITAL RD
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-0519
Mailing Address - Country:US
Mailing Address - Phone:662-862-9741
Mailing Address - Fax:662-862-3584
Practice Address - Street 1:301 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-0519
Practice Address - Country:US
Practice Address - Phone:662-862-9741
Practice Address - Fax:662-862-3584
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087670Medicaid
MS0767960001Medicare NSC
MST21144Medicare UPIN
MS560816290Medicare PIN