Provider Demographics
NPI:1053410126
Name:OPHTHALMIC PLASTIC SURGERY SPECIALISTS PLLC
Entity type:Organization
Organization Name:OPHTHALMIC PLASTIC SURGERY SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:SEGREST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-355-9537
Mailing Address - Street 1:1421 NORTH STATE ST
Mailing Address - Street 2:STE 304
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202
Mailing Address - Country:US
Mailing Address - Phone:601-355-9537
Mailing Address - Fax:601-355-6893
Practice Address - Street 1:1421 NORTH STATE ST
Practice Address - Street 2:STE 304
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-355-9537
Practice Address - Fax:601-355-6893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC7890OtherRAILROAD MEDICARE
MS00580070Medicaid
MSC03272Medicare ID - Type Unspecified
MS00580070Medicaid