Healthcare Provider Details

I. General information

NPI: 1669488490
Provider Name (Legal Business Name): JOHN T CHMELICEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SHELBY SPEIGHTS DR
PURVIS MS
39475-4151
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-794-8065
  • Fax: 601-794-5650
Mailing address:
  • Phone: 601-794-8065
  • Fax: 601-794-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13049
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: