MEDICARE: CROSSROAD EYE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	16628	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306869235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROAD EYE CENTER LLC

Provider Business Mailing Address
First Line	:	3035 CORDER DR
Second Line	:	PO BOX 1740
City	:	CORINTH
State	:	MS
Zip	:	38834-6216
Country	:	US
Telephone Number	:	662-286-9292
Fax Number	:	662-286-9293

Provider Business Practice Location Address
First Line	:	3035 CORDER DR
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-6216
Country	:	US
Telephone Number	:	662-286-9292
Fax Number	:	662-286-9293

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DARWIN B WOOTEN
Credential	:	M.D.
Telephone Number	:	662-286-9292

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	03/18/2008

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