Provider Demographics
NPI:1619939204
Name:NABORS, DEANNA (MD)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:NABORS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 GOODMAN RD E
Mailing Address - Street 2:STE 115
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9304
Mailing Address - Country:US
Mailing Address - Phone:662-890-5555
Mailing Address - Fax:662-420-7525
Practice Address - Street 1:3451 GOODMAN RD E STE 115
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9304
Practice Address - Country:US
Practice Address - Phone:662-890-5555
Practice Address - Fax:662-890-8899
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18687207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03037321Medicaid
MS03037321Medicaid
MSG20397Medicare UPIN