Healthcare Provider Details

I. General information

NPI: 1902882251
Provider Name (Legal Business Name): MISSISSIPPI ASTHMA & ALLERGY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 LAKELAND DR STE 100
JACKSON MS
39216-4829
US

IV. Provider business mailing address

1513 LAKELAND DR STE 101
JACKSON MS
39216-4829
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4836
  • Fax: 601-354-2619
Mailing address:
  • Phone: 601-354-4836
  • Fax: 601-354-2619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID L MOAK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 601-354-4836