Provider Demographics
NPI:1518937044
Name:WOOLDRIDGE, THOMAS D (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:WOOLDRIDGE
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 1:1542 MEDICAL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6560
Mailing Address - Country:US
Mailing Address - Phone:662-844-4711
Mailing Address - Fax:662-844-9619
Practice Address - Street 1:1542 MEDICAL PARK CIR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6560
Practice Address - Country:US
Practice Address - Phone:662-844-4711
Practice Address - Fax:662-844-9619
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6480207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0010676OtherBLUE CROSS BLUE SHIELD
73003901OtherBLUE CROSS PIN
MS00016236Medicaid
AL008604410Medicaid
MS6480OtherSTATE LICENSED NUMBER
GA390001766OtherRAILROAD MEDICARE PIN
MS6480OtherSTATE LICENSED NUMBER
MS6480OtherSTATE LICENSED NUMBER
MS390000022Medicare PIN
MS00016236Medicaid