Basic Information
| Provider Information | |||||||||
| NPI: | 1558688416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | LEPERCIVAL | ||||||||
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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: | 6019361395 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1860 CHADWICK DR STE 351 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392043472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013761288 | ||||||||
| FaxNumber: | 6013761293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2010 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22553 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07754391 | 05 | MS | MEDICAID |