Healthcare Provider Details

I. General information

NPI: 1740357334
Provider Name (Legal Business Name): MISSISSIPPI RETINA ASSOCIATES,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 BAPTIST CIR STE 400
MADISON MS
39110-2028
US

IV. Provider business mailing address

1200 N STATE ST SUITE 300
JACKSON MS
39202-2001
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-4091
  • Fax: 601-981-5039
Mailing address:
  • Phone: 601-981-4091
  • Fax: 601-981-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL JUDE BORNE
Title or Position: PRESIDENT
Credential:
Phone: 601-981-4091