Provider Demographics
NPI:1144320920
Name:ENNIS, CALVIN S (MD)
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:S
Last Name:ENNIS
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:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:ESCATAWPA
Mailing Address - State:MS
Mailing Address - Zip Code:39552-1358
Mailing Address - Country:US
Mailing Address - Phone:228-475-1166
Mailing Address - Fax:228-475-9337
Practice Address - Street 1:8006 HWY 613
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39562
Practice Address - Country:US
Practice Address - Phone:228-475-1166
Practice Address - Fax:228-475-9337
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115468Medicaid
MSD62935Medicare UPIN