Provider Demographics
NPI:1558422576
Name:GIVENS, RODERICK (MD)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:GIVENS
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 1:4 CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120
Mailing Address - Country:US
Mailing Address - Phone:601-597-7899
Mailing Address - Fax:601-446-9683
Practice Address - Street 1:4 CLUB DRIVE
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120
Practice Address - Country:US
Practice Address - Phone:601-597-7899
Practice Address - Fax:601-446-9683
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS149142085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117509Medicaid
MS$$$$$$$$$JOtherBCBS
MS$$$$$$$$$JOtherSTATE OF MISSISSIPPI
MS920000032Medicare PIN
MSF71973Medicare UPIN