Provider Demographics
NPI:1477621324
Name:WINDHAM, BEVERLY GWEN (MD)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:GWEN
Last Name:WINDHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:WINDHAM
Other - Last Name:OLDENQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DIVISION OF GERIATRICS
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5610
Mailing Address - Fax:601-984-5783
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF GERIATRICS
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5610
Practice Address - Fax:601-984-5783
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056056207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08952891Medicaid
MSP00783689Medicare PIN
MS302I385863Medicare PIN
MS08952891Medicaid