Provider Demographics
NPI:1831127422
Name:SLUIS, GORDON W (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:SLUIS
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 1:2200 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8246
Mailing Address - Country:US
Mailing Address - Phone:601-883-4133
Mailing Address - Fax:601-661-0985
Practice Address - Street 1:1115 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180
Practice Address - Country:US
Practice Address - Phone:601-634-8790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09812208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4627838OtherAETNA
LA1331287Medicaid
MS00013539Medicaid
MS00013539Medicaid
MSF50423Medicare UPIN
MS00013539Medicaid
LA1331287Medicaid