Provider Demographics
NPI:1164499190
Name:FORKS, THOMAS P (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:FORKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 408
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-292-4261
Mailing Address - Fax:601-292-4262
Practice Address - Street 1:7275 S SIWELL RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39272-9776
Practice Address - Country:US
Practice Address - Phone:601-373-7722
Practice Address - Fax:601-373-7378
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2010-12-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS12215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS753068151OtherMS HEALTH PARTNERS
MS753068151Other1ST CHOICE
MS00119587Medicaid
MS4253992OtherAETNA
MSP00138501OtherRAILROAD MEDICARE
MS168390702OtherDEPARTMENT OF LABOR
MS753068151008OtherTRICARE
MS753068151OtherMS PHYSICIANS CARE NETWOR
MS753068151OtherMS HEALTH PARTNERS
MS753068151OtherMS PHYSICIANS CARE NETWOR