Healthcare Provider Details

I. General information

NPI: 1477582096
Provider Name (Legal Business Name): JOSEPH A. KWENTUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3531 LAKELAND DRIVE SUITE 1060 BRENTWOOD PLAZA
FLOWOOD MS
39232
US

IV. Provider business mailing address

P.O. BOX 321015
FLOWOOD MS
39232
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-5810
  • Fax: 601-420-5811
Mailing address:
  • Phone: 601-420-5810
  • Fax: 601-420-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number17834
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number17834
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number17834
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number17834
License Number StateMS
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17834
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: