1518167832 NPI number — RENEE OKJA DYESS M.D.

Table of content: RENEE OKJA DYESS M.D. (NPI 1518167832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518167832 NPI number — RENEE OKJA DYESS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DYESS
Provider First Name:
RENEE
Provider Middle Name:
OKJA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1518167832
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 OLD HIGHWAY 43
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39047-8568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-954-5565
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 E METRO DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-4402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-992-3288
Provider Business Practice Location Address Fax Number:
601-992-3188
Provider Enumeration Date:
07/24/2007

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: 207Q00000X , with the licence number:  20104 , 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)

  • Identifier: 04139568 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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