Provider Demographics
NPI:1053474577
Name:OSWALT, CHRISTY TUCKER (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:TUCKER
Last Name:OSWALT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-9631
Mailing Address - Country:US
Mailing Address - Phone:662-680-6944
Mailing Address - Fax:
Practice Address - Street 1:65 S THOMAS ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4352
Practice Address - Country:US
Practice Address - Phone:662-842-7870
Practice Address - Fax:662-842-7873
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19214207R00000X
MS19414207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04971328Medicaid