Healthcare Provider Details

I. General information

NPI: 1740461201
Provider Name (Legal Business Name): T. KEVIN BRASWELL, MD P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 AVENT DR
GRENADA MS
38901-5002
US

IV. Provider business mailing address

990 AVENT DR
GRENADA MS
38901-5002
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-2030
  • Fax: 662-227-1236
Mailing address:
  • Phone: 662-226-2030
  • Fax: 662-227-1236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS LAURA TRUSTY
Title or Position: INSURANCE MANAGER
Credential:
Phone: 662-226-2030