Provider Demographics
NPI:1063403491
Name:WASHINGTON, CALVIN A (MD)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:A
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-928-4412
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:805 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2110
Practice Address - Country:US
Practice Address - Phone:601-928-4412
Practice Address - Fax:601-928-2479
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124266Medicaid
MS7499308OtherAETNA
MS7499308OtherAETNA
MSP00791971OtherRAILROAD MEDICARE
MS00124266Medicaid