Healthcare Provider Details

I. General information

NPI: 1669851697
Provider Name (Legal Business Name): DARRELL NETTLOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
KEESLER AFB MS
39534-2508
US

IV. Provider business mailing address

301 FISHER ST
KEESLER AFB MS
39534-2508
US

V. Phone/Fax

Practice location:
  • Phone: 228-376-2273
  • Fax:
Mailing address:
  • Phone: 228-376-3846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number29134
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number29134
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA155909
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29134
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA155909
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number330830
License Number StateLA
# 7
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number330830
License Number StateLA
# 8
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number61642
License Number StateMN
# 9
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA155909
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: