Healthcare Provider Details

I. General information

NPI: 1649473489
Provider Name (Legal Business Name): RICHARD STEPHEN PANNEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2086 OLD TAYLOR RD SUITE 1012
OXFORD MS
38655-5188
US

IV. Provider business mailing address

1739 UNIVERSITY AVE # 117
OXFORD MS
38655-4109
US

V. Phone/Fax

Practice location:
  • Phone: 662-380-5022
  • Fax: 662-380-5023
Mailing address:
  • Phone: 662-380-5022
  • Fax: 662-380-5023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number21831
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21831
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: