Healthcare Provider Details

I. General information

NPI: 1134552078
Provider Name (Legal Business Name): SYLVIA WINGO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SYLVIA JORDAN

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 W GOVERNMENT ST
BRANDON MS
39042-2408
US

IV. Provider business mailing address

PO BOX 1509
BRANDON MS
39043-1509
US

V. Phone/Fax

Practice location:
  • Phone: 601-825-3163
  • Fax:
Mailing address:
  • Phone: 601-825-7280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22598
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17704
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: