Provider Demographics
NPI:1225022213
Name:STUDDARD, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:STUDDARD
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 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 1052
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-981-9503
Mailing Address - Fax:601-951-7895
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 1052
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-981-9503
Practice Address - Fax:601-951-7895
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017817Medicaid
MSB30792Medicare UPIN
MS00017817Medicaid