Healthcare Provider Details

I. General information

NPI: 1659312585
Provider Name (Legal Business Name): KENNETH W STUBBS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 SERGEANT PRENTISS DR. SUITE 300
NATCHEZ MS
39120
US

IV. Provider business mailing address

46 SEARGENT PRENTISS DR. SUITE 300
NATCHEZ MS
39120
US

V. Phone/Fax

Practice location:
  • Phone: 601-446-2084
  • Fax: 601-442-3024
Mailing address:
  • Phone: 601-446-2084
  • Fax: 601-442-3024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15220
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number09681
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: