Healthcare Provider Details

I. General information

NPI: 1487388625
Provider Name (Legal Business Name): CRYSTAL N IBETOH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E MAIN ST STE 1
PHILADELPHIA MS
39350-2300
US

IV. Provider business mailing address

1120 E MAIN ST STE 1
PHILADELPHIA MS
39350-2300
US

V. Phone/Fax

Practice location:
  • Phone: 601-656-1465
  • Fax:
Mailing address:
  • Phone: 601-656-1465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37607
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: