Healthcare Provider Details

I. General information

NPI: 1669705372
Provider Name (Legal Business Name): RICHARD GRAY SLOAN JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2009
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 TUSCAN AVE
HATTIESBURG MS
39401-5461
US

IV. Provider business mailing address

498 TUSCAN AVE
HATTIESBURG MS
39401-5461
US

V. Phone/Fax

Practice location:
  • Phone: 601-318-6098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS10752
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number22621
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: