Provider Demographics
NPI:1619020401
Name:DODD, JOHN EDWIN JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWIN
Last Name:DODD
Suffix:JR
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 22846
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2846
Mailing Address - Country:US
Mailing Address - Phone:601-355-7246
Mailing Address - Fax:601-969-1173
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:SUITE 311A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-0200
Practice Address - Country:US
Practice Address - Phone:601-355-7246
Practice Address - Fax:601-969-1173
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10764207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018622Medicaid
MS00018622Medicaid