Provider Demographics
NPI:1184684375
Name:DOTSON, WAYNE ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ANTHONY
Last Name:DOTSON
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 1:907 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2830
Mailing Address - Country:US
Mailing Address - Phone:662-843-8880
Mailing Address - Fax:662-843-2280
Practice Address - Street 1:907 E SUNFLOWER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2830
Practice Address - Country:US
Practice Address - Phone:662-843-8880
Practice Address - Fax:662-843-2280
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16994174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123301Medicaid
MSG73818Medicare UPIN
MS00123301Medicaid