Healthcare Provider Details

I. General information

NPI: 1407968738
Provider Name (Legal Business Name): MINOR MED CARE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 MCDOWELL ROAD EXT
JACKSON MS
39204-4238
US

IV. Provider business mailing address

215 KATHERINE DR STE A
FLOWOOD MS
39232-9588
US

V. Phone/Fax

Practice location:
  • Phone: 601-372-1117
  • Fax: 601-373-3004
Mailing address:
  • Phone: 601-665-4162
  • Fax: 601-373-3004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number09740
License Number StateMS

VIII. Authorized Official

Name: CHRISTOPHER J WATKINS
Title or Position: CEO
Credential:
Phone: 601-665-4162