Healthcare Provider Details

I. General information

NPI: 1639205610
Provider Name (Legal Business Name): ROBERT E DILWORTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 22ND AVE MEDICAL TOWERS 3, 3RD FL
MERIDIAN MS
39301-3223
US

IV. Provider business mailing address

PO BOX 2839
MERIDIAN MS
39302-2839
US

V. Phone/Fax

Practice location:
  • Phone: 601-693-1055
  • Fax: 601-482-5312
Mailing address:
  • Phone: 601-703-3480
  • Fax: 601-703-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number07241
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: