Provider Demographics
NPI:1164467643
Name:BOULDIN, SHEILA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHEILA
Middle Name:
Last Name:BOULDIN
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5373
Mailing Address - Fax:601-984-5476
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5373
Practice Address - Fax:601-984-5476
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15149207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS178135Medicaid
MS512G700003OtherUP MEDICARE GROUP PROV #
MS160056544OtherRR MEDICARE NUMBER
MS512I160015OtherMEDICARE PTAN
MS00120467Medicaid
MS08103071OtherUP MEDICAID GROUP NUMBER
MS302I167015Medicare PIN
MS160056544OtherRR MEDICARE NUMBER
MS08103071OtherUP MEDICAID GROUP NUMBER
MSG92734Medicare UPIN