Healthcare Provider Details

I. General information

NPI: 1881115707
Provider Name (Legal Business Name): MITCHELL CRAIG MOFFETT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 TURNER ST
MABEN MS
39750-9157
US

IV. Provider business mailing address

1665 S GREEN ST
TUPELO MS
38804-6556
US

V. Phone/Fax

Practice location:
  • Phone: 662-397-7647
  • Fax:
Mailing address:
  • Phone: 662-377-2189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25953
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: