Provider Demographics
NPI:1619903580
Name:ERVIN, JAMES WILFRED JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WILFRED
Last Name:ERVIN
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 1:104 W RAILROAD AVE S
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-2111
Mailing Address - Country:US
Mailing Address - Phone:601-892-3063
Mailing Address - Fax:
Practice Address - Street 1:104 W RAILROAD AVE S
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2111
Practice Address - Country:US
Practice Address - Phone:601-892-3063
Practice Address - Fax:601-892-3570
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06726832Medicaid
MS06726832Medicaid
080003790Medicare PIN