Healthcare Provider Details

I. General information

NPI: 1912979592
Provider Name (Legal Business Name): BEN EARL KITCHENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 KAKI ST
IUKA MS
38852
US

IV. Provider business mailing address

302 KAKI ST
IUKA MS
38852
US

V. Phone/Fax

Practice location:
  • Phone: 662-423-3662
  • Fax: 662-423-2509
Mailing address:
  • Phone: 662-423-3662
  • Fax: 662-423-2509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number06296
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00007236
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: