Healthcare Provider Details

I. General information

NPI: 1275628125
Provider Name (Legal Business Name): WALTER G MAYFIELD JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

IV. Provider business mailing address

2403 WILLOW CHASE
TUPELO MS
38801-8164
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone: 662-680-4661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19026
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: