Provider Demographics
NPI:1700211141
Name:FOMIN, ALEXEY (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ALEXEY
Middle Name:
Last Name:FOMIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-288-7500
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:104 MILLSAPS DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1328
Practice Address - Country:US
Practice Address - Phone:601-288-7500
Practice Address - Fax:601-268-5179
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47117207R00000X
MS24153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04537068Medicaid
MS483843YKFFMedicare PIN