Individual
MS. MARY S MISSAK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
7680 AIRWAYS BLVD, SOUTHAVEN, MS 38671-5304
(662) 349-1999
(662) 349-9734
Mailing address
7680 AIRWAYS BLVD, SOUTHAVEN, MS 38671-5304
(662) 349-1999
(662) 349-9734
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
16715
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00122932
MAILHANDLERS
—
05
—
00122932
—
MS
01
—
3149420
TN BLUE CROSS FOR MS
TN
01
—
3152270
BLUE CROSS
TN
01
—
640922089001
CHAMPUS
TN
Enumeration date
09/13/2006
Last updated
07/08/2007
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