Provider Demographics
NPI:1730114117
Name:WARREN, ERIC JERMAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JERMAINE
Last Name:WARREN
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:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-0088
Mailing Address - Country:US
Mailing Address - Phone:601-824-0342
Mailing Address - Fax:601-824-0349
Practice Address - Street 1:613 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3038
Practice Address - Country:US
Practice Address - Phone:601-824-0342
Practice Address - Fax:601-824-0349
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS165172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125912Medicaid
MSH26996Medicare UPIN
MS260000634Medicare ID - Type Unspecified