Basic Information
| Provider Information | |||||||||
| NPI: | 1295932168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VESA | ||||||||
| FirstName: | TELCIANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 321359 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392321359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019336593 | ||||||||
| FaxNumber: | 6019336596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 CHADWICK DR STE 351 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392043472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013761288 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 2014015595 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 074924 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 21204 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1295932168 | 05 | MO | MEDICAID | 08278258 | 05 | MS | MEDICAID |