Provider Demographics
NPI:1851585004
Name:IVORY, DEDRI MARKITA (MD)
Entity Type:Individual
Prefix:MS
First Name:DEDRI
Middle Name:MARKITA
Last Name:IVORY
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 1:3510 PEMBERTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5506
Mailing Address - Country:US
Mailing Address - Phone:601-501-6991
Mailing Address - Fax:601-501-6987
Practice Address - Street 1:3510 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5506
Practice Address - Country:US
Practice Address - Phone:601-501-6991
Practice Address - Fax:601-501-6987
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21520207RR0500X
MO2009009253390200000X
OH57.011968390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
529450ZWJHMedicare PIN
MS302I665215Medicare PIN