=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922238161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL D. KILLOUGH, O.D. P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2009
-----------------------------------------------------
Last Update Date | 09/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 RED WOLF BLVD SUITE 101
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-910-5493
-----------------------------------------------------
Fax | 870-336-1775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 RED WOLF BLVD SUITE 101
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-910-5493
-----------------------------------------------------
Fax | 870-336-1775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL D KILLOUGH
-----------------------------------------------------
Credential | O.D. P.A.
-----------------------------------------------------
Telephone | 870-910-5493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | AR2528
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------