Provider Demographics
NPI:1437670080
Name:TARIQ, KATHLEEN BRIANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:BRIANNE
Last Name:TARIQ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:BRIANNE
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1431 W 10TH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2626
Mailing Address - Country:US
Mailing Address - Phone:601-649-1437
Mailing Address - Fax:601-649-1431
Practice Address - Street 1:1431 W 10TH ST STE 5
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2626
Practice Address - Country:US
Practice Address - Phone:601-649-1437
Practice Address - Fax:601-649-1431
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist