Provider Demographics
NPI:1790916294
Name:CONN, RHETTA A (OD)
Entity Type:Individual
Prefix:
First Name:RHETTA
Middle Name:A
Last Name:CONN
Suffix:
Gender:F
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:PO BOX 486
Mailing Address - Street 2:412 CENTRAL AVENUE
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-0486
Mailing Address - Country:US
Mailing Address - Phone:662-622-5173
Mailing Address - Fax:662-622-5590
Practice Address - Street 1:412 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MS
Practice Address - Zip Code:38618-3843
Practice Address - Country:US
Practice Address - Phone:662-622-5173
Practice Address - Fax:662-622-5590
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12077069OtherCAQH
MS02623217Medicaid
MS02623217Medicaid
MC2001179OtherDEA