Healthcare Provider Details

I. General information

NPI: 1073532693
Provider Name (Legal Business Name): GLENN GOLDRING OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E MAIN ST
SENATOBIA MS
38668-2138
US

IV. Provider business mailing address

106 E MAIN ST
SENATOBIA MS
38668-2138
US

V. Phone/Fax

Practice location:
  • Phone: 662-562-5500
  • Fax: 662-562-0600
Mailing address:
  • Phone: 662-562-5500
  • Fax: 662-562-0600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number673
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number673
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number468
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: