Healthcare Provider Details

I. General information

NPI: 1184885147
Provider Name (Legal Business Name): MISSISSIPPI FOOT CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 POINDEXTER ST
JACKSON MS
39203-3048
US

IV. Provider business mailing address

PO BOX 10529
JACKSON MS
39289-0529
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-0026
  • Fax: 601-355-0069
Mailing address:
  • Phone: 601-355-0026
  • Fax: 601-355-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number80062
License Number StateMS

VIII. Authorized Official

Name: DR. WILLIE JAMES LEWIS SR.
Title or Position: OWNER/PRESIDENT
Credential: D.P.M.
Phone: 601-355-0026