Healthcare Provider Details

I. General information

NPI: 1972564656
Provider Name (Legal Business Name): WESLEY F PRATER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1668 W PEACE ST
CANTON MS
39046-5332
US

IV. Provider business mailing address

PO BOX 588
CANTON MS
39046-0588
US

V. Phone/Fax

Practice location:
  • Phone: 601-859-5213
  • Fax: 601-859-8771
Mailing address:
  • Phone: 601-859-5213
  • Fax: 601-859-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number08247
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number08247
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: