Provider Demographics
NPI:1932372299
Name:MEDICAL PLAZA EYE CLINIC, P.A.
Entity type:Organization
Organization Name:MEDICAL PLAZA EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WOODY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-483-7331
Mailing Address - Street 1:5002 HWY 39 N
Mailing Address - Street 2:BLDG B
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1078
Mailing Address - Country:US
Mailing Address - Phone:601-483-7331
Mailing Address - Fax:601-483-3721
Practice Address - Street 1:5002 HWY 39 N
Practice Address - Street 2:BLDG B
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1078
Practice Address - Country:US
Practice Address - Phone:601-483-7331
Practice Address - Fax:601-483-3721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05260174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS13247Medicaid
AL8525OtherMEDICAID AL
MS13247Medicaid