Healthcare Provider Details

I. General information

NPI: 1720171002
Provider Name (Legal Business Name): JOANN ORPHANOS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15095 DEDEAUX ROAD
GULFPORT MS
39503-3284
US

IV. Provider business mailing address

15095 DEDEAUX ROAD
GULFPORT MS
39503-3284
US

V. Phone/Fax

Practice location:
  • Phone: 228-243-1238
  • Fax: 228-206-0503
Mailing address:
  • Phone: 228-243-1238
  • Fax: 228-206-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number80206
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: