Provider Demographics
NPI:1285791319
Name:TATUM, ROBERT ERVIN SR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ERVIN
Last Name:TATUM
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0667
Mailing Address - Country:US
Mailing Address - Phone:601-859-1929
Mailing Address - Fax:601-859-1926
Practice Address - Street 1:276B NISSAN PKWY
Practice Address - Street 2:STE 200
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-7032
Practice Address - Country:US
Practice Address - Phone:601-859-1929
Practice Address - Fax:601-859-1926
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS16155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120001Medicaid
MS00120001Medicaid
MSG84726Medicare UPIN