Healthcare Provider Details

I. General information

NPI: 1083804322
Provider Name (Legal Business Name): KIMBERLY A YEATES O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 12/10/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1913 HIGHWAY 45 N
COLUMBUS MS
39705-1950
US

IV. Provider business mailing address

834 HIGHWAY 12 W # 109
STARKVILLE MS
39759-3582
US

V. Phone/Fax

Practice location:
  • Phone: 601-917-0667
  • Fax:
Mailing address:
  • Phone: 601-917-0667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number782
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: