Provider Demographics
NPI:1316016066
Name:MARDIS, JOSEPH S (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:S
Last Name:MARDIS
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 24146
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4146
Mailing Address - Country:US
Mailing Address - Phone:601-815-4775
Mailing Address - Fax:601-984-6451
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-2005
Practice Address - Fax:601-984-6451
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07957509Medicaid
MS07957509Medicaid
G34365Medicare UPIN
110001049Medicare PIN
MS512I930195Medicare PIN