Provider Demographics
NPI:1376576884
Name:DESOTO EYECARE INC
Entity Type:Organization
Organization Name:DESOTO EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHAEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-349-1959
Mailing Address - Street 1:726 GOODMAN RD E STE B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9530
Mailing Address - Country:US
Mailing Address - Phone:662-349-1959
Mailing Address - Fax:662-349-0424
Practice Address - Street 1:726 GOODMAN RD E STE B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-349-1959
Practice Address - Fax:662-349-0424
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESOTO EYECARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-08
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14992302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSV07496Medicare UPIN
TN3723748Medicare PIN
MS180000264Medicare PIN
MS4245630001Medicare NSC
MSA13768Medicare UPIN