Provider Demographics
NPI:1043314057
Name:STALLWORTH, GREGORY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:STALLWORTH
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 1:1430 HWY 4-EAST
Mailing Address - Street 2:P.O. BOX 6000
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38634
Mailing Address - Country:US
Mailing Address - Phone:662-551-3369
Mailing Address - Fax:662-551-3421
Practice Address - Street 1:1430 HWY 4-EAST
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38634
Practice Address - Country:US
Practice Address - Phone:662-551-3369
Practice Address - Fax:662-551-3421
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00578207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116623Medicaid
MS00116623Medicaid
MS930002371Medicare ID - Type Unspecified