1942243712 NPI number — QUINTON HOWARD DICKERSON JR. MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942243712 NPI number — QUINTON HOWARD DICKERSON JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
QUINTON
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942243712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
970 LAKELAND DR
Provider Second Line Business Mailing Address:
SUITE 61
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-982-7850
Provider Business Mailing Address Fax Number:
601-718-5145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
970 LAKELAND DR
Provider Second Line Business Practice Location Address:
SUITE 61
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-982-7850
Provider Business Practice Location Address Fax Number:
601-718-5145
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  5261 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00014082 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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