Provider Demographics
NPI:1306925029
Name:OBRIEN, MICHAEL EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:OBRIEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1890 GOODMAN RD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9552
Mailing Address - Country:US
Mailing Address - Phone:662-772-5882
Mailing Address - Fax:662-772-5808
Practice Address - Street 1:1890 GOODMAN RD E
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9552
Practice Address - Country:US
Practice Address - Phone:662-772-5882
Practice Address - Fax:662-772-5808
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015435Medicaid
MS09015435Medicaid
MS512I410030Medicare PIN