Healthcare Provider Details

I. General information

NPI: 1689614240
Provider Name (Legal Business Name): KIMBERLY ANN CROWDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST SUITE B319
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST SUITE B319
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-4788
  • Fax: 601-815-3773
Mailing address:
  • Phone: 601-984-5022
  • Fax: 601-815-3773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number17144
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: