Provider Demographics
NPI:1679565428
Name:PADDOCK, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:PADDOCK
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:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502
Mailing Address - Country:US
Mailing Address - Phone:228-575-1600
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-575-1600
Practice Address - Fax:228-575-1603
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015310174400000X
MS32690208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1335169Medicaid
LA5M242Medicare ID - Type Unspecified
LA1335169Medicaid