Provider Demographics
NPI:1124048277
Name:FORD, REAGAN LEE SR (OD)
Entity type:Individual
Prefix:DR
First Name:REAGAN
Middle Name:LEE
Last Name:FORD
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:706F HIGHWAY 12 W
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3573
Mailing Address - Country:US
Mailing Address - Phone:662-323-0571
Mailing Address - Fax:662-323-6365
Practice Address - Street 1:706F HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3573
Practice Address - Country:US
Practice Address - Phone:662-323-0571
Practice Address - Fax:662-323-6365
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087840Medicaid
MS00087840Medicaid