Basic Information
| Provider Information | |||||||||
| NPI: | 1922080316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2106 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393022106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034282 | ||||||||
| FaxNumber: | 6017033080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 CENTRAL DR | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393508972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016566921 | ||||||||
| FaxNumber: | 6016560381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207Q00000X | 05295 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080121055 | 01 | RAILROAD MEDICARE | OTHER | 00110589 | 05 | MS | MEDICAID | 288056YJ8J | 01 | MS | MEDICARE | OTHER |