Provider Demographics
NPI:1063402782
Name:PURVIS, JANI L (MD)
Entity type:Individual
Prefix:MRS
First Name:JANI
Middle Name:L
Last Name:PURVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANI
Other - Middle Name:
Other - Last Name:BURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39602-0764
Mailing Address - Country:US
Mailing Address - Phone:601-833-8511
Mailing Address - Fax:601-835-5413
Practice Address - Street 1:108 LANCE ALWORTH DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2300
Practice Address - Country:US
Practice Address - Phone:601-833-8511
Practice Address - Fax:601-835-5413
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS138842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0119693Medicaid
G76679Medicare UPIN