Provider Demographics
NPI:1669441218
Name:PATTERSON, WILFORD J (M D)
Entity Type:Individual
Prefix:
First Name:WILFORD
Middle Name:J
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 408
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-924-9005
Mailing Address - Fax:601-925-9463
Practice Address - Street 1:106 CLINTON PKWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4730
Practice Address - Country:US
Practice Address - Phone:601-924-9005
Practice Address - Fax:601-925-9463
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS168390703OtherUS DEPT OF LABOR
MS4225044OtherAETNA
MS753068151OtherMS HEALTH PARTNERS
MS753068151Other1ST CHOICE
MS753068151OtherMS PHYSICIANS CARE NETWOR
MS753068151001OtherTRICARE
MSP00062075OtherRR MEDICARE
MS00012345Medicaid
MS00012345Medicaid
MS4225044OtherAETNA
MSB30225Medicare UPIN