Healthcare Provider Details

I. General information

NPI: 1972536837
Provider Name (Legal Business Name): JOHN M FAUST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/25/2014
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

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-2538
  • Fax: 601-815-1854
Mailing address:
  • Phone: 601-984-2538
  • Fax: 601-815-1854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number08729
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: