Basic Information
| Provider Information | |||||||||
| NPI: | 1528060522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039632 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034282 | ||||||||
| FaxNumber: | 6017034597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 17079 | MS | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0105X | 17079 | MS | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009948470 | 01 | AL | MEDICAID OF AL | OTHER | 009948470 | 01 | AL | BLUE CROSS OF AL | OTHER | 00123534 | 05 | MS | MEDICAID | 418195297 | 01 | TRICARE | OTHER |