Provider Demographics
NPI:1306843131
Name:CANDELORA, JOSEPH N (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:N
Last Name:CANDELORA
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:PO BOX 55873
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-5873
Mailing Address - Country:US
Mailing Address - Phone:601-362-1319
Mailing Address - Fax:601-362-9569
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-6757
Practice Address - Fax:601-200-8801
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08190207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121875Medicaid
2444281OtherWESTERN OHIO HEALTHCARE
4004816OtherBC OF TN
7128306OtherAETNA
7128306OtherAETNA