Healthcare Provider Details

I. General information

NPI: 1215137096
Provider Name (Legal Business Name): DANIEL GREGORY STEVENS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1842 SIMPSON HIGHWAY 149
MENDENHALL MS
39114-3438
US

IV. Provider business mailing address

PO BOX 15722
HATTIESBURG MS
39404-5722
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-2424
  • Fax: 601-847-2199
Mailing address:
  • Phone: 601-288-1823
  • Fax: 601-288-1877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number002556
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: