Healthcare Provider Details

I. General information

NPI: 1558382200
Provider Name (Legal Business Name): DESOTO OSTEOPATHIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 STATELINE RD E SUITE #10
SOUTHAVEN MS
38671-1704
US

IV. Provider business mailing address

187 STATELINE RD E SUITE #10
SOUTHAVEN MS
38671-1704
US

V. Phone/Fax

Practice location:
  • Phone: 662-342-5353
  • Fax: 662-393-9753
Mailing address:
  • Phone: 662-342-5353
  • Fax: 662-393-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15380
License Number StateMS

VIII. Authorized Official

Name: MRS. DEBBIE CLARK
Title or Position: BILLER
Credential:
Phone: 662-429-5221