Provider Demographics
NPI:1700918729
Name:BROWN, CHRISTINA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:MARIE
Last Name:BROWN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CHRISTINA
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1890 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9504
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:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9504
Practice Address - Country:US
Practice Address - Phone:662-772-5882
Practice Address - Fax:662-772-5808
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1505403Medicaid
TN3590063Medicare PIN