Provider Demographics
NPI:1245290386
Name:POE, KATRINA (MD)
Entity type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:
Last Name:POE
Suffix:
Gender:F
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:PO BOX 6338
Mailing Address - Street 2:
Mailing Address - City:MISSISSIPPI STATE
Mailing Address - State:MS
Mailing Address - Zip Code:39762-6338
Mailing Address - Country:US
Mailing Address - Phone:662-325-2431
Mailing Address - Fax:662-325-8888
Practice Address - Street 1:360 HARDY ROAD
Practice Address - Street 2:
Practice Address - City:MISISSIPPI STATE UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:39762
Practice Address - Country:US
Practice Address - Phone:662-325-2431
Practice Address - Fax:662-325-8888
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124231Medicaid
MS00124231Medicaid