Healthcare Provider Details

I. General information

NPI: 1710979323
Provider Name (Legal Business Name): DAVID I. DOORENBOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 12TH ST
MERIDIAN MS
39301-4158
US

IV. Provider business mailing address

1800 12TH ST
MERIDIAN MS
39301-4158
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-3074
  • Fax:
Mailing address:
  • Phone: 601-703-3074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number11711
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: