Healthcare Provider Details

I. General information

NPI: 1154833572
Provider Name (Legal Business Name): OXFORD EYE CLINIC & OPTICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2167 S LAMAR BLVD
OXFORD MS
38655-5223
US

IV. Provider business mailing address

2167 S LAMAR BLVD
OXFORD MS
38655-5223
US

V. Phone/Fax

Practice location:
  • Phone: 662-234-6683
  • Fax: 662-234-4413
Mailing address:
  • Phone: 662-234-6683
  • Fax: 662-234-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN SHELTON WALLY
Title or Position: OPTOMETRIST/OWNER
Credential: OD
Phone: 601-341-1399