Healthcare Provider Details

I. General information

NPI: 1801884234
Provider Name (Legal Business Name): SAMUEL D HENSLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 LAKELAND DR
FLOWOOD MS
39232-9513
US

IV. Provider business mailing address

2510 LAKELAND DR
FLOWOOD MS
39232-9513
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-1234
  • Fax: 601-326-3559
Mailing address:
  • Phone: 601-355-1234
  • Fax: 601-326-3559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number12771
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number12771
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: