Provider Demographics
NPI:1962780023
Name:TIEU, BRIAN C (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:TIEU
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 SUNDIAL RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8772
Mailing Address - Country:US
Mailing Address - Phone:601-984-5017
Mailing Address - Fax:601-984-5042
Practice Address - Street 1:281 TRACE COLONY PARK DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3915
Practice Address - Country:US
Practice Address - Phone:601-324-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23344207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06238338Medicaid
MS428257YJ5DMedicare PIN
MS06238338Medicaid