Healthcare Provider Details

I. General information

NPI: 1538276191
Provider Name (Legal Business Name): FLAVIA H WEST MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FLAVIA H WEST MD

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 S MAIN ST
PONTOTOC MS
38863-3209
US

IV. Provider business mailing address

PO DRAWER 450
PONTOTOC MS
38863
US

V. Phone/Fax

Practice location:
  • Phone: 662-489-5038
  • Fax: 662-489-7004
Mailing address:
  • Phone: 662-489-5038
  • Fax: 662-489-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10750
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: