Provider Demographics
NPI:1528096849
Name:SUDDERTH, STEPHEN D (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:SUDDERTH
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 1:188 YMCA PL
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-3536
Mailing Address - Country:US
Mailing Address - Phone:601-636-7222
Mailing Address - Fax:601-636-0440
Practice Address - Street 1:188 YMCA PL
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-3536
Practice Address - Country:US
Practice Address - Phone:601-636-7222
Practice Address - Fax:601-636-0440
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17597208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126115Medicaid
LA1986712Medicaid
MSF78937Medicare UPIN
MS00126115Medicaid
LA1986712Medicaid
MS5012649OtherAETNA
MS020000450Medicare PIN