Provider Demographics
NPI:1306942503
Name:KILLOUGH, MICHAEL DON (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DON
Last Name:KILLOUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1801 RED WOLF BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5450
Mailing Address - Country:US
Mailing Address - Phone:870-910-5493
Mailing Address - Fax:870-336-1775
Practice Address - Street 1:1801 RED WOLF BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5450
Practice Address - Country:US
Practice Address - Phone:870-910-5493
Practice Address - Fax:870-336-1775
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2528152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49893OtherABCBS
AR5G341Medicare PIN
AR49893OtherABCBS