Provider Demographics
NPI:1073661344
Name:BRADSHAW, JOYCE (MD)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-4030
Mailing Address - Country:US
Mailing Address - Phone:601-636-0097
Mailing Address - Fax:601-629-9969
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:601-636-0097
Practice Address - Fax:601-629-9969
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09744207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123284Medicaid
MS00123284Medicaid
MS220000153Medicare PIN