Provider Demographics
NPI:1912947144
Name:CLARK, KEVIN GRAFTON (OD, PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GRAFTON
Last Name:CLARK
Suffix:
Gender:M
Credentials:OD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 HIGHWAY 25
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-6148
Mailing Address - Country:US
Mailing Address - Phone:601-919-0040
Mailing Address - Fax:601-919-0083
Practice Address - Street 1:5310 HIGHWAY 25
Practice Address - Street 2:SUITE 5
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6148
Practice Address - Country:US
Practice Address - Phone:601-919-0040
Practice Address - Fax:601-919-0083
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087918Medicaid
MST21245Medicare UPIN
MS512 I 41 0025Medicare PIN