1154401909 NPI number — DR. FANASY PROKOP JEFCOAT D.M.D., MS

Table of content: DR. FANASY PROKOP JEFCOAT D.M.D., MS (NPI 1154401909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154401909 NPI number — DR. FANASY PROKOP JEFCOAT D.M.D., MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEFCOAT
Provider First Name:
FANASY
Provider Middle Name:
PROKOP
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D., MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154401909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2044 TIDEWATER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-8927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-605-6511
Provider Business Mailing Address Fax Number:
601-605-6508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 WEBSTER CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-605-6511
Provider Business Practice Location Address Fax Number:
601-605-6508
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  3251-03 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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