Healthcare Provider Details

I. General information

NPI: 1477526945
Provider Name (Legal Business Name): DECLAN F HEGARTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 DEWEY ST
LUCEDALE MS
39452-5707
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-766-0308
  • Fax: 601-766-0309
Mailing address:
  • Phone: 601-766-0308
  • Fax: 601-766-0309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME94859
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25465
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: