Healthcare Provider Details

I. General information

NPI: 1699478693
Provider Name (Legal Business Name): AVERY VILLERET MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PARK CREEK DR
COLUMBUS MS
39705-1309
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 662-327-8410
  • Fax: 662-327-9749
Mailing address:
  • Phone: 877-348-1281
  • Fax: 901-227-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT-4951
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: