Healthcare Provider Details

I. General information

NPI: 1689057721
Provider Name (Legal Business Name): JOHN THAMES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 AZALEA DR S
WIGGINS MS
39577
US

IV. Provider business mailing address

1428 AZALEA DR S
WIGGINS MS
39577-8195
US

V. Phone/Fax

Practice location:
  • Phone: 601-928-9674
  • Fax: 601-928-5963
Mailing address:
  • Phone: 601-928-9674
  • Fax: 601-928-5963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number24548
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24548
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: