Provider Demographics
NPI:1427121268
Name:THARP, PAMELA DIANE (OD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:DIANE
Last Name:THARP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6351 INTERSTATE 55 NORTH,
Mailing Address - Street 2:STE. 115-B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:601-991-9723
Mailing Address - Fax:601-991-9745
Practice Address - Street 1:6351 INTERSTATE 55 NORTH,
Practice Address - Street 2:STE. 115-B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-991-9723
Practice Address - Fax:601-991-9745
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880103Medicaid
MS410000165Medicare ID - Type Unspecified
U59381Medicare UPIN