Provider Demographics
NPI:1215929104
Name:WELDON, THOMAS E (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:WELDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:785 OHIO AVE
Mailing Address - Street 2:3E
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6217
Mailing Address - Country:US
Mailing Address - Phone:662-624-3435
Mailing Address - Fax:662-627-5440
Practice Address - Street 1:785 OHIO AVE
Practice Address - Street 2:SUITE 3E
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6217
Practice Address - Country:US
Practice Address - Phone:662-624-5621
Practice Address - Fax:662-624-5691
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09380208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00019972Medicaid
MS04371729Medicaid
MS340000100Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE#
MSB64132Medicare UPIN
MS00019972Medicaid
MS0664130001Medicare NSC