Provider Demographics
NPI:1740353515
Name:SKELTON, DEBORAH S (MD)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:S
Last Name:SKELTON
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 1:500 LONG LEAF PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-5535
Mailing Address - Country:US
Mailing Address - Phone:601-362-7252
Mailing Address - Fax:888-222-6996
Practice Address - Street 1:971 LAKELAND DR STE 1160
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4609
Practice Address - Country:US
Practice Address - Phone:601-981-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09701207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
100006764OtherRAILROAD MEDICARE PROVIDR
MS100000057OtherMEDICARE PTAN
MS09701OtherMS MEDICAL LICENSE NUMBER
MS03576701Medicaid
MS03576701Medicaid
64-0854894OtherFEDERAL TAX ID NUMBER
BS0733356OtherDEA REGISTRATION