Provider Demographics
NPI:1578510962
Name:ESPOSITO, DOMENIC P (MD)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:P
Last Name:ESPOSITO
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 1:2500 N STATE ST
Mailing Address - Street 2:N703 NEUROSURGERY DEPARTMENT
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5706
Mailing Address - Fax:601-984-6491
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:N703 NEUROSURGERY DEPARTMENT
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5706
Practice Address - Fax:601-984-6491
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS16712207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS140000133Other2007 MCR
MS140006643OtherRR PTAN
MS00122202Medicaid
MS00122202Medicaid