Provider Demographics
NPI:1770833501
Name:HUDDLESTON, PAUL RUSS (PT, ATP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:RUSS
Last Name:HUDDLESTON
Suffix:
Gender:M
Credentials:PT, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100B4 GT THAMES DRIVE
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759
Mailing Address - Country:US
Mailing Address - Phone:662-615-1870
Mailing Address - Fax:662-615-1871
Practice Address - Street 1:100B4 GT THAMES DRIVE
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-615-1870
Practice Address - Fax:662-615-1871
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1681208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation