Healthcare Provider Details

I. General information

NPI: 1902814361
Provider Name (Legal Business Name): KENNETH RAY DAUGHTREY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S HOLLY AVE
COLLINS MS
39428-3894
US

IV. Provider business mailing address

PO BOX 55
SEMINARY MS
39479-0055
US

V. Phone/Fax

Practice location:
  • Phone: 601-765-6711
  • Fax: 601-698-0186
Mailing address:
  • Phone: 601-506-7468
  • Fax: 601-429-9403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11516
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: