Provider Demographics
NPI:1689038168
Name:YELVERTON, SAMUEL RUFFIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:RUFFIN
Last Name:YELVERTON
Suffix:
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 1:971 LAKELAND DR STE 1460
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4684
Mailing Address - Country:US
Mailing Address - Phone:601-951-7583
Mailing Address - Fax:601-982-3259
Practice Address - Street 1:971 LAKELAND DR STE 1460
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4684
Practice Address - Country:US
Practice Address - Phone:601-982-3202
Practice Address - Fax:601-982-3259
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28227208600000X
NC218753208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty