Healthcare Provider Details

I. General information

NPI: 1598884561
Provider Name (Legal Business Name): DELTA PHYSICIAN PRACTICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1693 S COLORADO ST
GREENVILLE MS
38703-7211
US

IV. Provider business mailing address

PO BOX 23998
JACKSON MS
39225-3998
US

V. Phone/Fax

Practice location:
  • Phone: 662-332-8700
  • Fax: 662-332-3005
Mailing address:
  • Phone: 662-725-2749
  • Fax: 662-725-2741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IRIS STACKER
Title or Position: CEO
Credential:
Phone: 662-378-3783