Provider Demographics
NPI:1356363915
Name:FORD, JOHN R (MS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:FORD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3711
Mailing Address - Country:US
Mailing Address - Phone:601-636-8244
Mailing Address - Fax:
Practice Address - Street 1:1901 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-636-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124996Medicaid
MS080003482Medicare ID - Type Unspecified
MSB30400Medicare UPIN