Healthcare Provider Details

I. General information

NPI: 1679505507
Provider Name (Legal Business Name): JASON H MCCLOUD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E MAIN ST
GRAYSON KY
41143-1301
US

IV. Provider business mailing address

107 E MAIN ST
GRAYSON KY
41143-1301
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-5149
  • Fax: 606-474-0648
Mailing address:
  • Phone: 606-474-5149
  • Fax: 606-474-0648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1585DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: