Provider Demographics
NPI:1649278573
Name:CARTER, THADDEUS COX (MD)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:COX
Last Name:CARTER
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-863-4490
Mailing Address - Fax:228-863-7238
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2418
Practice Address - Country:US
Practice Address - Phone:228-863-4490
Practice Address - Fax:228-863-7238
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08995174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00019775Medicaid
MS340000302Medicare PIN
MS512I340022Medicare PIN
MSP00647496Medicare PIN
MSB30111Medicare UPIN
MSP00405480Medicare PIN