Provider Demographics
NPI:1790777142
Name:CAUSEY, JACK Q II (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:Q
Last Name:CAUSEY
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:19648 CHAMPION CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-7668
Mailing Address - Country:US
Mailing Address - Phone:601-865-3653
Mailing Address - Fax:228-575-2380
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-867-4000
Practice Address - Fax:228-575-2380
Is Sole Proprietor?:No
Enumeration Date:2005-08-20
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS11872207ZP0102X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC47960Medicare UPIN
P00384618Medicare PIN