Healthcare Provider Details

I. General information

NPI: 1780762534
Provider Name (Legal Business Name): THOMAS D. AMANKONAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-4540
  • Fax: 601-984-4548
Mailing address:
  • Phone: 601-984-4540
  • Fax: 601-984-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number24335
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: