Healthcare Provider Details

I. General information

NPI: 1669784930
Provider Name (Legal Business Name): JUSTIN ALAN QUALLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

312 W LAWSON ST
CLINTON MS
39056-4116
US

V. Phone/Fax

Practice location:
  • Phone: 601-985-5532
  • Fax:
Mailing address:
  • Phone: 601-917-8952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22402
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22402
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: