Healthcare Provider Details

I. General information

NPI: 1962603886
Provider Name (Legal Business Name): ALAIN LESAGE FONDJO DOMKAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 10/25/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 8TH ST
GREENWOOD MS
38930-4014
US

IV. Provider business mailing address

302 8TH ST
GREENWOOD MS
38930-4014
US

V. Phone/Fax

Practice location:
  • Phone: 662-451-4570
  • Fax: 662-451-5140
Mailing address:
  • Phone: 662-451-4570
  • Fax: 662-451-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number19760
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: