Healthcare Provider Details

I. General information

NPI: 1336238443
Provider Name (Legal Business Name): COLE FACIAL PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 N FLOWOOD DR STE A
JACKSON MS
39232-9532
US

IV. Provider business mailing address

1030 N. FLOWOOD DR. STE A
JACKSON MS
39232
US

V. Phone/Fax

Practice location:
  • Phone: 601-933-2004
  • Fax: 601-896-0112
Mailing address:
  • Phone: 601-933-2004
  • Fax: 601-896-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number15530
License Number StateMS

VIII. Authorized Official

Name: MR. JEPTHA NEWTON COLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-933-2004