Provider Demographics
NPI:1225072838
Name:DESHAZO, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:DESHAZO
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 1:878 LAKELAND DR
Mailing Address - Street 2:LB-BUILDING
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-1078
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:878 LAKELAND DR
Practice Address - Street 2:LB-BUILDING
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-1078
Practice Address - Fax:601-984-6994
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15660207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0019701Medicaid
MSC67445Medicare UPIN
MS302I037060Medicare PIN