Healthcare Provider Details

I. General information

NPI: 1881685220
Provider Name (Legal Business Name): GLEN H STRIBLING OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E GEORGETOWN ST
CRYSTAL SPRINGS MS
39059-2746
US

IV. Provider business mailing address

110 E GEORGETOWN ST
CRYSTAL SPRINGS MS
39059-2746
US

V. Phone/Fax

Practice location:
  • Phone: 601-892-5053
  • Fax: 601-892-5741
Mailing address:
  • Phone: 601-892-5053
  • Fax: 601-892-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number516
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: