Provider Demographics
NPI:1295932168
Name:VESA, TELCIANE (MD)
Entity type:Individual
Prefix:
First Name:TELCIANE
Middle Name:
Last Name:VESA
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 321359
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1359
Mailing Address - Country:US
Mailing Address - Phone:601-933-6593
Mailing Address - Fax:601-933-6596
Practice Address - Street 1:1860 CHADWICK DR STE 351
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3472
Practice Address - Country:US
Practice Address - Phone:601-376-1288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014015595207RG0100X
GA074924207RG0100X
MS21204207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1295932168Medicaid
MS08278258Medicaid