Healthcare Provider Details

I. General information

NPI: 1821296237
Provider Name (Legal Business Name): DAVID WAYNE KELTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPT. OF EMERGENCY MEDICINE
JACKSON MS
39216-4500
US

IV. Provider business mailing address

360 HERITAGE PL
JACKSON MS
39212-5825
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5582
  • Fax:
Mailing address:
  • Phone: 773-793-8118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number688-L
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-124819
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21214
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: