Provider Demographics
NPI:1386982569
Name:FLAVIA H WEST MD
Entity type:Organization
Organization Name:FLAVIA H WEST MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLAVIA
Authorized Official - Middle Name:H
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-489-5038
Mailing Address - Street 1:183 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-3209
Mailing Address - Country:US
Mailing Address - Phone:662-489-5038
Mailing Address - Fax:662-489-7004
Practice Address - Street 1:183 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-3209
Practice Address - Country:US
Practice Address - Phone:662-489-5038
Practice Address - Fax:662-489-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00019567Medicaid
MS00019567Medicaid