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General NPI Number Information
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NPI Number | 1891179768
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Entity Type | Organization
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Legal Business Name | DESOTO CHILDREN'S CLINIC - OLIVE BRANCH
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Dates
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Enumeration Date | 07/10/2015
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Last Update Date | 05/02/2023
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Provider Practice Location Address
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Address Line | 7145 GOODMAN ROAD
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City | OLIVE BRANCH
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State | MS
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Zip | 38654
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Country | US
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Telephone | 662-333-5001
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Fax | 662-420-7063
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Provider Business Mailing Address
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Address Line | 7145 GOODMAN ROAD
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City | OLIVE BRANCH
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State | MS
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Zip | 38654
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Country | US
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Telephone | 662-333-5001
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Fax | 662-420-7063
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Authorized Official
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Title or Position | MD
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Name | MR. DESH DEEPAK SIDHU
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Credential | MD
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Telephone | 662-562-4418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State | MS
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