Provider Demographics
NPI:1962490755
Name:TATE, DARREN R (MD)
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:R
Last Name:TATE
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 1:2100 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8211
Mailing Address - Country:US
Mailing Address - Phone:601-883-5000
Mailing Address - Fax:601-883-5196
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:601-883-5196
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3851174400000X
MS19641207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08575770Medicaid
TX168286601Medicaid
LA1028185Medicaid
MS7442608OtherAETNA
MS08575770Medicaid
8B4864Medicare ID - Type Unspecified
LA1028185Medicaid
MS160000805Medicare PIN