Provider Demographics
NPI:1659384063
Name:LIDDELL, KENTRELL MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENTRELL
Middle Name:MARIE
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 THOUSAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-2048
Mailing Address - Country:US
Mailing Address - Phone:601-346-7450
Mailing Address - Fax:601-346-7451
Practice Address - Street 1:2104 THOUSAND OAKS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-2048
Practice Address - Country:US
Practice Address - Phone:601-346-7450
Practice Address - Fax:601-346-7451
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08072071Medicaid
MS11859914OtherUNITED HEALTHCARE
MS11859914OtherUNITED HEALTHCARE
MS08072071Medicaid
MS$$$$$$$$$AOtherBLUE CROSS BLUE SHIELD OF MS
MS080004304Medicare PIN