Healthcare Provider Details

I. General information

NPI: 1780664706
Provider Name (Legal Business Name): MARY GRACE SUMMERS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 CLUB PKWY
CORDOVA TN
38016-5977
US

IV. Provider business mailing address

8045 CLUB PKWY
CORDOVA TN
38016-5977
US

V. Phone/Fax

Practice location:
  • Phone: 901-758-1384
  • Fax: 901-758-1394
Mailing address:
  • Phone: 901-758-1384
  • Fax: 901-758-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1429
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4092194
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier2240091
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerUNITED HEALTH CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: