Healthcare Provider Details

I. General information

NPI: 1538199831
Provider Name (Legal Business Name): ANGELOS BASIL VAMVAKAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3161 WAYNE DR
DIBERVILLE MS
39540-8554
US

IV. Provider business mailing address

3161 WAYNE DR
DIBERVILLE MS
39540-8554
US

V. Phone/Fax

Practice location:
  • Phone: 228-392-2730
  • Fax:
Mailing address:
  • Phone: 228-392-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18343
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: