Healthcare Provider Details

I. General information

NPI: 1922006279
Provider Name (Legal Business Name): VIRGIL ISAAC AULTMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2747 OLD CANTON RD
JACKSON MS
39216-4308
US

IV. Provider business mailing address

2747 OLD CANTON RD
JACKSON MS
39216-4308
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-6452
  • Fax: 601-366-6488
Mailing address:
  • Phone: 601-366-6452
  • Fax: 601-366-6488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number06153
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: