Healthcare Provider Details

I. General information

NPI: 1679784599
Provider Name (Legal Business Name): MATTHEW LEE OSWALT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 GARFIELD ST
TUPELO MS
38801-5748
US

IV. Provider business mailing address

811 GARFIELD ST
TUPELO MS
38801-5748
US

V. Phone/Fax

Practice location:
  • Phone: 662-620-0688
  • Fax: 601-620-0684
Mailing address:
  • Phone: 662-620-0688
  • Fax: 601-620-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number18939
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: