Healthcare Provider Details

I. General information

NPI: 1912986480
Provider Name (Legal Business Name): KEVIN PETRONELA JUOZAPAVICIUS D.O., MS, BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 INDEPENDENCE COLUMBUS AFB
COLUMBUS MS
39710-5300
US

IV. Provider business mailing address

1087 STARK RD APT 5E
STARKVILLE MS
39759-3537
US

V. Phone/Fax

Practice location:
  • Phone: 662-434-2273
  • Fax:
Mailing address:
  • Phone: 918-510-0116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4305
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.010626
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: