Provider Demographics
NPI:1104955301
Name:THOMAS, DAISY MARIE (MD)
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:MARIE
Last Name:THOMAS
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 1:500 CCC ROAD
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038
Mailing Address - Country:US
Mailing Address - Phone:662-247-3831
Mailing Address - Fax:
Practice Address - Street 1:500 CCC ROAD
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038
Practice Address - Country:US
Practice Address - Phone:662-247-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07839207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018415Medicaid
MSAT7524843OtherDEA
MSAT7524843OtherDEA