Healthcare Provider Details

I. General information

NPI: 1558421651
Provider Name (Legal Business Name): GREGORY ALVIN AUZENNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/17/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4803 29TH AVE STE A
MERIDIAN MS
39305-2675
US

IV. Provider business mailing address

PO BOX 649107
DALLAS TX
75264
US

V. Phone/Fax

Practice location:
  • Phone: 601-286-5477
  • Fax: 601-286-5825
Mailing address:
  • Phone: 601-286-5477
  • Fax: 601-286-5825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20220
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number20220
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: