Provider Demographics
NPI:1942212543
Name:SHERROD, CLIDE S (MD)
Entity Type:Individual
Prefix:
First Name:CLIDE
Middle Name:S
Last Name:SHERROD
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:PO BOX 31165
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33631-3165
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:405-844-1794
Practice Address - Street 1:801 GOODYEAR BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3221
Practice Address - Country:US
Practice Address - Phone:601-798-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14122207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1411663Medicaid
MSP00806416OtherRRMCARE THRU HCCN
AR159370001Medicaid
MS00114489Medicaid
E19886Medicare UPIN
MS00114489Medicaid
MS302I932911Medicare PIN