Provider Demographics
NPI:1558382200
Name:DESOTO OSTEOPATHIC
Entity Type:Organization
Organization Name:DESOTO OSTEOPATHIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-429-5221
Mailing Address - Street 1:187 STATELINE RD E
Mailing Address - Street 2:SUITE #10
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1704
Mailing Address - Country:US
Mailing Address - Phone:662-342-5353
Mailing Address - Fax:662-393-9753
Practice Address - Street 1:187 STATELINE RD E
Practice Address - Street 2:SUITE #10
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1704
Practice Address - Country:US
Practice Address - Phone:662-342-5353
Practice Address - Fax:662-393-9753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4031960OtherBLUE CROSS OF TENNESSEE
MS0118418Medicaid
MS0118418Medicaid