Provider Demographics
NPI:1053511626
Name:NORRIS, DAVID RONALD (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RONALD
Last Name:NORRIS
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-4778
Mailing Address - Fax:601-984-5420
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF FAMILY MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-4778
Practice Address - Fax:601-984-5420
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS30208I7759OtherMEDICARE PTAN
LA2195603Medicaid
MS30208I7759OtherMEDICARE PTAN
MS302I088820Medicare PIN