Healthcare Provider Details

I. General information

NPI: 1316149040
Provider Name (Legal Business Name): MARILYN DAVIDSON GRAVES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/08/2007
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

4035 OAKRIDGE DR
JACKSON MS
39216-3414
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-7554
  • Fax: 601-815-3226
Mailing address:
  • Phone: 601-815-7554
  • Fax: 601-815-3226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number05990
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: