Provider Demographics
NPI:1922032481
Name:HUCKABAY, CHADWICK PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHADWICK
Middle Name:PAUL
Last Name:HUCKABAY
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5185
Mailing Address - Fax:601-984-5190
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:601-984-5185
Practice Address - Fax:601-984-5190
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48147208800000X
MS20977208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1044163OtherPREFERRED ONE
MN19-00700OtherMEDICA CHOICE
MN842988000Medicaid
IA0597914Medicaid
AL157409Medicaid
MSP01227738OtherRR MCR
MN19-00018OtherMEDICA PRIMARY
MNHP54551OtherHEALTHPARTNERS
MS04509838Medicaid
MN132996OtherUCARE
MN2376915OtherARAZ
MN490K6HUOtherBCBS
MN19-00700OtherMEDICA CHOICE
MSP01227738OtherRR MCR
MN132996OtherUCARE
MN340000857Medicare ID - Type UnspecifiedMEDICARE
AL157409Medicaid