Healthcare Provider Details

I. General information

NPI: 1356920656
Provider Name (Legal Business Name): ALBERT VACHERON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N 1ST ST
BOONEVILLE MS
38829-2718
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 662-340-1138
  • Fax: 662-728-5185
Mailing address:
  • Phone: 901-226-4003
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number34844
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number73859
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: