Healthcare Provider Details

I. General information

NPI: 1891179768
Provider Name (Legal Business Name): DESOTO CHILDREN'S CLINIC - OLIVE BRANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7145 GOODMAN ROAD
OLIVE BRANCH MS
38654
US

IV. Provider business mailing address

7145 GOODMAN ROAD
OLIVE BRANCH MS
38654
US

V. Phone/Fax

Practice location:
  • Phone: 662-333-5001
  • Fax: 662-420-7063
Mailing address:
  • Phone: 662-333-5001
  • Fax: 662-420-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: MR. DESH DEEPAK SIDHU
Title or Position: MD
Credential: MD
Phone: 662-562-4418