Individual
JEREMY BLAKE WELLS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
103 MEDICAL PARK FL 2, HATTIESBURG, MS 39401-9042
(601) 268-5630
(601) 579-3285
Mailing address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 268-5630
(601) 579-5240
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
T-2501
MS
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
22493
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
06927265
—
MS
Enumeration date
07/01/2011
Last updated
05/09/2024
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