Provider Demographics
NPI:1548671514
Name:BLUE, MARKETTA
Entity type:Individual
Prefix:
First Name:MARKETTA
Middle Name:
Last Name:BLUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-741-8800
Mailing Address - Fax:662-741-8895
Practice Address - Street 1:702 MARTIN LUTHER KING ST
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762-9314
Practice Address - Country:US
Practice Address - Phone:662-741-8800
Practice Address - Fax:662-741-8895
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine