Provider Demographics
NPI:1619188026
Name:GRIFFIN, KAISHA RENADA (MD)
Entity Type:Individual
Prefix:DR
First Name:KAISHA
Middle Name:RENADA
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MASON COVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-709-5130
Practice Address - Fax:601-709-5151
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2011-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MST-1990208000000X
MS21093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program