Provider Demographics
NPI:1306869235
Name:CROSSROAD EYE CENTER LLC
Entity type:Organization
Organization Name:CROSSROAD EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DARWIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-286-9292
Mailing Address - Street 1:3035 CORDER DR
Mailing Address - Street 2:PO BOX 1740
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6216
Mailing Address - Country:US
Mailing Address - Phone:662-286-9292
Mailing Address - Fax:662-286-9293
Practice Address - Street 1:3035 CORDER DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6216
Practice Address - Country:US
Practice Address - Phone:662-286-9292
Practice Address - Fax:662-286-9293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16628207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122436Medicaid
MS01087285Medicaid
5444420001Medicare NSC
MS00122436Medicaid