| Interventional Diabetes Center, LLC | |
|
20735 Highway 12 Lexington MS 39095-8266 | |
| (601) 594-7346 | |
| Not Available |
| Full Name | Interventional Diabetes Center, LLC |
|---|---|
| Speciality | Clinic/Center |
| Location | 20735 Highway 12, Lexington, Mississippi |
| Authorized Official Name and Position | Maurice Hampton (OWNER) |
| Authorized Official Contact | 9017911711 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Interventional Diabetes Center, LLC 20735 Highway 12 Lexington MS 39095-8266 Ph: (901) 791-1711 | Interventional Diabetes Center, LLC 20735 Highway 12 Lexington MS 39095-8266 Ph: (601) 594-7346 |
| NPI Number | 1649747825 |
|---|---|
| Provider Enumeration Date | 10/25/2018 |
| Last Update Date | 05/06/2025 |
| Certification Date | 05/05/2025 |
| Medicare PECOS PAC ID | 1254742935 |
|---|---|
| Medicare Enrollment ID | O20201202000228 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1649747825 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | () | Primary |
| Provider Name | Percy Anderson |
|---|---|
| Provider Type | Practitioner - Podiatry |
| Provider Identifiers | NPI Number: 1982792198 PECOS PAC ID: 9638148174 Enrollment ID: I20040930000655 |
| Provider Name | Miranda D White |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427568260 PECOS PAC ID: 8628334604 Enrollment ID: I20171107002470 |
| Provider Name | Omar Davis |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1588767826 PECOS PAC ID: 8921012444 Enrollment ID: I20250609002956 |
| Provider Name | Antonio Knowles |
|---|---|
| Provider Type | Practitioner - Podiatry |
| Provider Identifiers | NPI Number: 1124188511 PECOS PAC ID: 7315842085 Enrollment ID: I20251219000558 |
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