Provider Demographics
NPI:1639374218
Name:STARKVILLE UROLOGY, PLLC
Entity Type:Organization
Organization Name:STARKVILLE UROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONACIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-324-1097
Mailing Address - Street 1:1207 HIGHWAY 182 W STE B
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-9013
Mailing Address - Country:US
Mailing Address - Phone:662-324-1097
Mailing Address - Fax:662-324-2412
Practice Address - Street 1:1207 HIGHWAY 182 W STE B
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-9013
Practice Address - Country:US
Practice Address - Phone:662-324-1097
Practice Address - Fax:662-324-2412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17324208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124405Medicaid
MSC03014Medicare PIN