Provider Demographics
NPI:1902867021
Name:IMPERIAL, ANTONIO JAIME TORRES JR (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO JAIME
Middle Name:TORRES
Last Name:IMPERIAL
Suffix:JR
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 1:415 S 28TH AVE
Mailing Address - Street 2:HATTIESBURG CLINIC PA
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8262
Mailing Address - Country:US
Mailing Address - Phone:601-288-4329
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-288-4329
Practice Address - Fax:601-288-3191
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19010208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640507572ZWOtherAMERICAN ADMIN GROUP
MS07835294Medicaid
LA1501131Medicaid
P00272265OtherRAILROAD MEDICARE
MS07835294Medicaid
MS110001919Medicare PIN