Provider Demographics
NPI:1225046543
Name:THREADGILL, STEPHEN TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:TODD
Last Name:THREADGILL
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 1:1208 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-3597
Mailing Address - Country:US
Mailing Address - Phone:662-234-9888
Mailing Address - Fax:662-281-8927
Practice Address - Street 1:1208 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3597
Practice Address - Country:US
Practice Address - Phone:662-234-9888
Practice Address - Fax:662-281-8927
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11791207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112961Medicaid
MS100000039Medicare ID - Type Unspecified
MSC79301Medicare UPIN