Provider Demographics
NPI:1447315254
Name:PACE, J MINOR (OD)
Entity type:Individual
Prefix:DR
First Name:J
Middle Name:MINOR
Last Name:PACE
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 1:100 AIRPORT RD S
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-6654
Mailing Address - Country:US
Mailing Address - Phone:601-939-3753
Mailing Address - Fax:601-936-6586
Practice Address - Street 1:100 AIRPORT RD S
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-6654
Practice Address - Country:US
Practice Address - Phone:601-939-3753
Practice Address - Fax:601-936-6586
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0880171Medicaid
MST98163Medicare UPIN
MS0880171Medicaid