Provider Demographics
NPI:1720013428
Name:WOFFORD, MARION R (MD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:R
Last Name:WOFFORD
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 1:2500 N STATE ST
Mailing Address - Street 2:GENERAL INTERNAL MEDICINE-HYPERTENSION
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6525
Mailing Address - Fax:601-984-6853
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE/HYPERTENSION
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6525
Practice Address - Fax:601-984-6853
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13910207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053341Medicaid
MS0116903Medicaid
MSP00462361OtherRAILROAD MEDICARE PTAN
MSP1271440OtherRAILROAD MEDICARE
MS302I117078Medicare PIN
MS512I110024Medicare PIN
MS0116903Medicaid
MS110000842Medicare PIN