Provider Demographics
NPI:1205935269
Name:DOTSON, RENIA R (MD)
Entity type:Individual
Prefix:
First Name:RENIA
Middle Name:R
Last Name:DOTSON
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 1:1636 ANNE STOKES RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-6907
Mailing Address - Country:US
Mailing Address - Phone:662-334-9691
Mailing Address - Fax:
Practice Address - Street 1:1727 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3253
Practice Address - Country:US
Practice Address - Phone:662-332-0040
Practice Address - Fax:662-332-5008
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16993208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015528Medicaid
MSH07439Medicare UPIN
MS09015528Medicaid