Provider Demographics
NPI:1043233372
Name:PRATHER, JOHN WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYNE
Last Name:PRATHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 ALCORN DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9321
Mailing Address - Country:US
Mailing Address - Phone:662-287-5218
Mailing Address - Fax:662-286-3186
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:SUITE 230
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9321
Practice Address - Country:US
Practice Address - Phone:662-287-5218
Practice Address - Fax:662-286-3186
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS08877207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017652Medicaid
C48368Medicare UPIN
MS00017652Medicaid