Healthcare Provider Details

I. General information

NPI: 1861715534
Provider Name (Legal Business Name): MISSISSIPPI ASTHMA AND ALLERGY CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2886 SOUTH LAMAR BLVD
OXFORD MS
38655-7905
US

IV. Provider business mailing address

1513 LAKELAND DR SUITE 101
JACKSON MS
39216-4829
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4836
  • Fax:
Mailing address:
  • Phone: 601-354-4836
  • Fax: 601-354-2619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number09 00008210
License Number StateMS

VIII. Authorized Official

Name: DAVID L MOAK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 601-354-4836