Provider Demographics
NPI:1962507061
Name:MISSAK, MARY S (MD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:S
Last Name:MISSAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7680 AIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5304
Mailing Address - Country:US
Mailing Address - Phone:662-349-1999
Mailing Address - Fax:662-349-9734
Practice Address - Street 1:7680 AIRWAYS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5304
Practice Address - Country:US
Practice Address - Phone:662-349-1999
Practice Address - Fax:662-349-9734
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3152270OtherBLUE CROSS
00122932OtherMAILHANDLERS
TN640922089001OtherCHAMPUS
MS00122932Medicaid
TN3149420OtherTN BLUE CROSS FOR MS
TN3152270OtherBLUE CROSS
G79720Medicare UPIN