Provider Demographics
NPI:1518046234
Name:OBRIEN VISION CENTER, P.A.
Entity type:Organization
Organization Name:OBRIEN VISION CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-772-5882
Mailing Address - Street 1:1890 GOODMAN RD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9552
Mailing Address - Country:US
Mailing Address - Phone:662-772-5882
Mailing Address - Fax:662-772-5808
Practice Address - Street 1:1890 GOODMAN RD E
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9552
Practice Address - Country:US
Practice Address - Phone:662-772-5882
Practice Address - Fax:662-772-5808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880166Medicaid
MS00880166Medicaid