Provider Demographics
NPI:1588109821
Name:RETINA SPECIALISTS OF MISSISSIPPI, PLLC
Entity type:Organization
Organization Name:RETINA SPECIALISTS OF MISSISSIPPI, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WRIGHT
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAUTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-255-0736
Mailing Address - Street 1:109 MILLSAPS DR STE B
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1587
Mailing Address - Country:US
Mailing Address - Phone:601-255-0736
Mailing Address - Fax:
Practice Address - Street 1:109 MILLSAPS DR STE B
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1587
Practice Address - Country:US
Practice Address - Phone:601-255-0736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21600207W00000X
207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty