Healthcare Provider Details

I. General information

NPI: 1356366355
Provider Name (Legal Business Name): SHARON PATRICIA DOUGLAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE 14A
JACKSON MS
39216-5116
US

IV. Provider business mailing address

129 CYPRESS LAKE BLVD S
MADISON MS
39110-7316
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-1463
  • Fax: 601-364-1429
Mailing address:
  • Phone: 601-853-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number11352
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: