Provider Demographics
NPI:1578627782
Name:DAVID M. HEADLEY, M.D. PA
Entity Type:Organization
Organization Name:DAVID M. HEADLEY, M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEZELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-437-3323
Mailing Address - Street 1:PO BOX 676
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-0676
Mailing Address - Country:US
Mailing Address - Phone:601-437-3323
Mailing Address - Fax:601-437-8499
Practice Address - Street 1:405 MARKET ST
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2024
Practice Address - Country:US
Practice Address - Phone:601-437-3323
Practice Address - Fax:601-437-8499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DN3465OtherRAILROAD MEDICARE
MS09015175Medicaid
B64376Medicare UPIN
MSC02844Medicare PIN