Provider Demographics
NPI:1932135522
Name:WITCHER, JOHN EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWIN
Last Name:WITCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 142
Mailing Address - Street 2:EAST CENTRAL MS HEALTH CARE INC
Mailing Address - City:SEBASTOPOL
Mailing Address - State:MS
Mailing Address - Zip Code:39359
Mailing Address - Country:US
Mailing Address - Phone:601-625-7140
Mailing Address - Fax:601-625-7199
Practice Address - Street 1:1488 HWY 487
Practice Address - Street 2:SEBASTOPOL CLINIC
Practice Address - City:SEBASTOPOL
Practice Address - State:MS
Practice Address - Zip Code:39359
Practice Address - Country:US
Practice Address - Phone:601-625-7403
Practice Address - Fax:601-625-7404
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14977207Q00000X, 208D00000X, 208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126975Medicaid
G31525Medicare UPIN
MSG31525Medicare UPIN