Provider Demographics
NPI:1811932072
Name:POOLE, CALVIN P (MD)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:P
Last Name:POOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:40 UNION CHURCH RD
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653-0636
Mailing Address - Country:US
Mailing Address - Phone:601-384-8112
Mailing Address - Fax:601-384-4100
Practice Address - Street 1:595 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653-9233
Practice Address - Country:US
Practice Address - Phone:601-384-8112
Practice Address - Fax:601-384-4100
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS09173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122580Medicaid
MS09013856Medicaid
MS00122580Medicaid
MS080003722Medicare PIN
MS251330Medicare Oscar/Certification