Provider Demographics
NPI:1972572683
Name:GORTON, SIDNEY CARLTON (MD)
Entity type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:CARLTON
Last Name:GORTON
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:PO BOX 633
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-0633
Mailing Address - Country:US
Mailing Address - Phone:662-247-2105
Mailing Address - Fax:
Practice Address - Street 1:107 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038-3929
Practice Address - Country:US
Practice Address - Phone:662-247-2105
Practice Address - Fax:662-247-4849
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1082827Medicaid
MS110001811Medicare ID - Type Unspecified