Provider Demographics
NPI:1730298506
Name:GADDY, IRA EUGENE III (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:EUGENE
Last Name:GADDY
Suffix:III
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 1:10051 LORRAINE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-6001
Mailing Address - Country:US
Mailing Address - Phone:228-539-7762
Mailing Address - Fax:228-539-4953
Practice Address - Street 1:10051 LORRAINE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-6001
Practice Address - Country:US
Practice Address - Phone:228-539-7762
Practice Address - Fax:228-539-4953
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08343174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06303560Medicaid
MS00013310Medicaid
MS5114250001Medicare NSC
MSD73593Medicare UPIN
MSC02879Medicare ID - Type Unspecified