Healthcare Provider Details

I. General information

NPI: 1346235223
Provider Name (Legal Business Name): CLIFFORD WAYNE BREWER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 HIGHWAY 90 SUITE 1402
GAUTIER MS
39553-5115
US

IV. Provider business mailing address

2800 HIGHWAY 90 SUITE 1402
GAUTIER MS
39553-5115
US

V. Phone/Fax

Practice location:
  • Phone: 228-497-2020
  • Fax: 228-497-4820
Mailing address:
  • Phone: 228-497-2020
  • Fax: 228-497-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number548
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: