Healthcare Provider Details

I. General information

NPI: 1528261815
Provider Name (Legal Business Name): PANDYA-LIPMAN EYE SPECIALIST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PHYSICIANS LN SUITE 2
SOUTHAVEN MS
38671-6122
US

IV. Provider business mailing address

60 PHYSICIANS LN SUITE 1
SOUTHAVEN MS
38671-6122
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-3025
  • Fax: 662-349-0708
Mailing address:
  • Phone: 662-349-3025
  • Fax: 662-349-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number16645
License Number StateMS

VIII. Authorized Official

Name: MRS. TRACI L CATO
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-349-3025