Provider Demographics
NPI:1316290067
Name:VIANA, ANDRES G (PHD)
Entity type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:G
Last Name:VIANA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5855
Mailing Address - Fax:601-984-5857
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF PSYCHIATRY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5855
Practice Address - Fax:601-984-5857
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS52908103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06073391Medicaid
MS259508YK9BMedicare PIN