Healthcare Provider Details

I. General information

NPI: 1164499190
Provider Name (Legal Business Name): THOMAS P FORKS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7275 S SIWELL RD
JACKSON MS
39272-9776
US

IV. Provider business mailing address

1151 N STATE ST SUITE 408
JACKSON MS
39202-2407
US

V. Phone/Fax

Practice location:
  • Phone: 601-373-7722
  • Fax: 601-373-7378
Mailing address:
  • Phone: 601-292-4261
  • Fax: 601-292-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12215
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: