Provider Demographics
NPI:1053404012
Name:KEA, JOE CHADDRICK (OD)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:CHADDRICK
Last Name:KEA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 TUPELO COMMONS STE 101
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-9791
Mailing Address - Country:US
Mailing Address - Phone:662-231-1895
Mailing Address - Fax:662-842-0379
Practice Address - Street 1:3437 TUPELO COMMONS
Practice Address - Street 2:SUITE 101
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9791
Practice Address - Country:US
Practice Address - Phone:662-842-2000
Practice Address - Fax:662-842-0379
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS578152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880031Medicaid
MS00880031Medicaid
MS410000098Medicare ID - Type UnspecifiedMISSISSIPPI MEDICARE
MSU35305Medicare UPIN