Healthcare Provider Details

I. General information

NPI: 1194750653
Provider Name (Legal Business Name): WILLIAM MANLEY WADSWORTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 HIGHWAY 51 S
HERNANDO MS
38632-1737
US

IV. Provider business mailing address

2240 HIGHWAY 51 S
HERNANDO MS
38632-1737
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5231
  • Fax: 662-429-4922
Mailing address:
  • Phone: 662-429-5231
  • Fax: 662-429-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14009
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: