Provider Demographics
NPI:1235646670
Name:PHILLIPS, JASPER LOUIS JR (MD)
Entity Type:Individual
Prefix:
First Name:JASPER
Middle Name:LOUIS
Last Name:PHILLIPS
Suffix:JR
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 1:2522 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-7102
Mailing Address - Country:US
Mailing Address - Phone:252-522-0095
Mailing Address - Fax:
Practice Address - Street 1:2522 DOGWOOD LN
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-7102
Practice Address - Country:US
Practice Address - Phone:252-522-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14275208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty