Healthcare Provider Details

I. General information

NPI: 1790917383
Provider Name (Legal Business Name): JAMES H MASTERS CIDDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 SPRINGHILL RD
LAUREL MS
39443-8996
US

IV. Provider business mailing address

809 SPRINGHILL RD
LAUREL MS
39443-8996
US

V. Phone/Fax

Practice location:
  • Phone: 601-705-1901
  • Fax:
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0485
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: