Healthcare Provider Details

I. General information

NPI: 1629371018
Provider Name (Legal Business Name): RICHARD L YELVERTON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 RIVER OAKS DR STE 102
JACKSON MS
39232-9539
US

IV. Provider business mailing address

971 LAKELAND DR STE 1460
JACKSON MS
39216-4621
US

V. Phone/Fax

Practice location:
  • Phone: 601-933-5660
  • Fax: 601-933-5670
Mailing address:
  • Phone: 601-957-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number04433
License Number StateMS

VIII. Authorized Official

Name: RICHARD L YELVERTON
Title or Position: PRESIDENT
Credential: MD
Phone: 601-957-7340