Provider Demographics
NPI:1922238161
Name:MICHAEL D. KILLOUGH, O.D. P.A.
Entity type:Organization
Organization Name:MICHAEL D. KILLOUGH, O.D. P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KILLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD PA
Authorized Official - Phone:870-910-5493
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2528152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155151722Medicaid
AR155151722Medicaid
AR5G341Medicare PIN