Provider Demographics
NPI:1780755173
Name:REED, ROGER H (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:H
Last Name:REED
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 1:15444 DEDEAUX RD
Mailing Address - Street 2:STE. B
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2637
Mailing Address - Country:US
Mailing Address - Phone:228-832-9038
Mailing Address - Fax:228-832-9990
Practice Address - Street 1:15444 DEDEAUX RD
Practice Address - Street 2:STE. B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-832-9038
Practice Address - Fax:228-832-9990
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00014184Medicaid
MS080001252Medicare ID - Type UnspecifiedPREVIOUS TAX ID
MS00014184Medicaid
MS930002920Medicare ID - Type Unspecified