Provider Demographics
NPI:1962575472
Name:BELK EYE CLINIC, PA
Entity type:Organization
Organization Name:BELK EYE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:BELK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:228-832-1832
Mailing Address - Street 1:12199 HIGHWAY 49 STE 100
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3167
Mailing Address - Country:US
Mailing Address - Phone:228-832-1832
Mailing Address - Fax:
Practice Address - Street 1:12199 HIGHWAY 49 STE 100
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3167
Practice Address - Country:US
Practice Address - Phone:228-832-1832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0932320001Medicare NSC