Provider Demographics
NPI:1164430419
Name:SISTRUNK, JOHN WOODY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WOODY
Last Name:SISTRUNK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 353
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-949-6990
Mailing Address - Fax:601-949-6105
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 353
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-949-6990
Practice Address - Fax:601-949-6105
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2010-10-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS15819207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124713Medicaid
MS00124713Medicaid
MSG44238Medicare UPIN