Basic Information
Provider Information | |||||||||
NPI: | 1134102296 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUNGAN | ||||||||
FirstName: | VINCENT | ||||||||
MiddleName: | CRAIG | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. DRAWER 1769 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393021769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017039506 | ||||||||
FaxNumber: | 6017033264 | ||||||||
Practice Location | |||||||||
Address1: | 1800 12TH ST | ||||||||
Address2: | SUITE 1D | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393014158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017039541 | ||||||||
FaxNumber: | 6017039947 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2005 | ||||||||
LastUpdateDate: | 11/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 12833 | MS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 009937735 | 05 | AL |   | MEDICAID | 731-04039 | 01 |   | BLUE CROSS OF AL | OTHER | P00070814 | 01 |   | RAILROAD MEDICARE | OTHER | 00112842 | 05 | MS |   | MEDICAID |