Healthcare Provider Details

I. General information

NPI: 1376004549
Provider Name (Legal Business Name): PATRICK STOVALL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 09/28/2023
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 13TH ST
GULFPORT MS
39501
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-4396
  • Fax: 228-867-5354
Mailing address:
  • Phone: 228-575-1194
  • Fax: 228-575-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31781
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number31781
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: