Provider Demographics
NPI:1992839088
Name:CALLAHAN, BRIAN SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
Last Name:CALLAHAN
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 1:5520 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-8926
Mailing Address - Country:US
Mailing Address - Phone:601-932-1890
Mailing Address - Fax:601-932-3119
Practice Address - Street 1:5520 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-8926
Practice Address - Country:US
Practice Address - Phone:601-932-1890
Practice Address - Fax:601-932-3119
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS590152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07321OtherSPECTERA
MS03755233Medicaid
MSU57480Medicare UPIN