Provider Demographics
NPI:1750472643
Name:PHILLIPS, DEIRDRE M (MD)
Entity Type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:M
Last Name:PHILLIPS
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 1:1888 MAIN ST STE C
Mailing Address - Street 2:BOX 277
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6337
Mailing Address - Country:US
Mailing Address - Phone:601-594-2609
Mailing Address - Fax:
Practice Address - Street 1:1888 MAIN ST STE C
Practice Address - Street 2:BOX 277
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6337
Practice Address - Country:US
Practice Address - Phone:601-594-2609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07045207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0112697Medicaid
MSB30104Medicare UPIN