Provider Demographics
NPI:1164510491
Name:THAGGARD, ANSON L (MD)
Entity Type:Individual
Prefix:DR
First Name:ANSON
Middle Name:L
Last Name:THAGGARD
Suffix:
Gender:M
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 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-2538
Mailing Address - Fax:601-815-1854
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-2538
Practice Address - Fax:601-815-1854
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS132162085N0904X, 2085R0202X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00203599Medicaid
MSP01202306OtherRAILROAD MEDICARE PTAN
AL179025Medicaid
POO634041OtherRAILROAD MEDICARE
MS333158YWZ1Medicare PIN
POO634041OtherRAILROAD MEDICARE
MS00203599Medicaid