Healthcare Provider Details

I. General information

NPI: 1336197649
Provider Name (Legal Business Name): MABEL ZEVALLOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST STE 270
JACKSON MS
39202-2027
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-6470
  • Fax:
Mailing address:
  • Phone: 901-227-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberN6794
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number19001
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: