Provider Demographics
NPI:1326248774
Name:STEPHENS, JAMES WYATT (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WYATT
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-587-0209
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:128 COURTHOUSE SQ
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-6014
Practice Address - Country:US
Practice Address - Phone:601-587-0209
Practice Address - Fax:601-587-0436
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS262986839OtherTRICARE
MS9697227OtherAETNA
MS05180817Medicaid
MS9697227OtherAETNA
MS05180817Medicaid
MS262986839OtherTRICARE