Provider Demographics
NPI:1083942338
Name:SHIVES, JASON LEE (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:SHIVES
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 1:102 SHELBY SPEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-4151
Mailing Address - Country:US
Mailing Address - Phone:601-794-8065
Mailing Address - Fax:601-794-5650
Practice Address - Street 1:102 SHELBY SPEIGHTS DR
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4151
Practice Address - Country:US
Practice Address - Phone:601-794-8065
Practice Address - Fax:601-794-5650
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102839207P00000X
PAMD470029207P00000X
390200000X
MS21360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program