Healthcare Provider Details

I. General information

NPI: 1184629818
Provider Name (Legal Business Name): WILSON E MOAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N STATE ST STE 403
JACKSON MS
39202-2413
US

IV. Provider business mailing address

1190 N STATE ST STE 403
JACKSON MS
39202-2413
US

V. Phone/Fax

Practice location:
  • Phone: 601-353-2020
  • Fax: 601-714-5110
Mailing address:
  • Phone: 601-353-2020
  • Fax: 601-714-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number06305
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: