Organization
DESOTO FAMILY MEDICAL PRACTICE, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KAREN M TATE (SECRETARY)
(662) 895-3700
Entity
Organization
Contact information
Practice address
7163 GOODMAN RD, OLIVE BRANCH, MS 38654-1904
(662) 895-3700
(662) 895-4886
Mailing address
7163 GOODMAN RD, P. O. BOX 518, OLIVE BRANCH, MS 38654-1904
(662) 895-3700
(662) 895-4886
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
512G700011
MEDICARE IDENTIFICATION NUMBER
MS
Enumeration date
08/12/2006
Last updated
11/19/2011
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