Provider Demographics
NPI:1851913172
Name:MOHYUDIN, ADIL
Entity Type:Individual
Prefix:
First Name:ADIL
Middle Name:
Last Name:MOHYUDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 POPLAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-3382
Mailing Address - Country:US
Mailing Address - Phone:779-875-6139
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-584-5601
Practice Address - Fax:601-984-6665
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MST-4060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program