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General NPI Number Information
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NPI Number | 1831276278
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Entity Type | Individual
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Provider Name | GRADY MIMS CLARK JR. O.D.
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Gender | Male
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 09/11/2018
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Provider Practice Location Address
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Address Line | 2112 N FRONTAGE RD
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City | MERIDIAN
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State | MS
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Zip | 39301-6158
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Country | US
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Telephone | 601-693-2020
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Fax | 601-693-2690
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Provider Business Mailing Address
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Address Line | 2112 N FRONTAGE RD
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City | MERIDIAN
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State | MS
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Zip | 39301-6158
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Country | US
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Telephone | 601-693-2020
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Fax | 601-693-2690
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 457
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 457
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License Number State | MS
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