Healthcare Provider Details

I. General information

NPI: 1255144044
Provider Name (Legal Business Name): BROWN FAMILY RETINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6760 GOODMAN RD STE 125
OLIVE BRANCH MS
38654-9893
US

IV. Provider business mailing address

6760 GOODMAN RD STE 125
OLIVE BRANCH MS
38654-9893
US

V. Phone/Fax

Practice location:
  • Phone: 662-782-5404
  • Fax: 662-405-0345
Mailing address:
  • Phone: 662-782-5404
  • Fax: 662-405-0345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CALVIN CHRISTOPHER BROWN
Title or Position: SURGEON
Credential: MD
Phone: 662-782-5404