Provider Demographics
NPI:1225142458
Name:LINDSTROM, ERIC EVERETT (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:EVERETT
Last Name:LINDSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0407
Mailing Address - Country:US
Mailing Address - Phone:601-426-9454
Mailing Address - Fax:601-426-9476
Practice Address - Street 1:1020 ADAMS ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4365
Practice Address - Country:US
Practice Address - Phone:601-426-9454
Practice Address - Fax:601-426-9476
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07529207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0015799Medicaid
MS0015799Medicaid