Healthcare Provider Details

I. General information

NPI: 1912818386
Provider Name (Legal Business Name): 360 MEDICAL GROUP MISSISSIPPI PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 MAGNOLIA ST UNIT 1-A5
GULFPORT MS
39507-4106
US

IV. Provider business mailing address

270 TRACE COLONY PARK DR STE B
RIDGELAND MS
39157-8810
US

V. Phone/Fax

Practice location:
  • Phone: 833-360-6388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES VILLAR
Title or Position: ADMINISTRATOR
Credential:
Phone: 833-360-6388