Provider Demographics
NPI:1538154117
Name:CALZADA, JORGE I (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:I
Last Name:CALZADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 AIRWAYS BLVD BLDG A1
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4116
Mailing Address - Country:US
Mailing Address - Phone:901-522-6520
Mailing Address - Fax:901-522-6521
Practice Address - Street 1:7900 AIRWAYS BLVD BLDG A1
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4116
Practice Address - Country:US
Practice Address - Phone:417-889-2040
Practice Address - Fax:417-889-2041
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39266207WX0107X
MS19430207WX0107X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05172706Medicaid
MS3370388OtherMEDICARE GRP
MO1538154117Medicaid
AR163874001Medicaid
TN3329131Medicaid
MS3370388OtherMEDICARE GRP
TN3709016OtherMEDICARE GRP
AL181950Medicaid