Provider Demographics
NPI:1992704530
Name:ABIDE, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:ABIDE
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 1:481 CYPRESS LN
Mailing Address - Street 2:APT. A103
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7473
Mailing Address - Country:US
Mailing Address - Phone:662-332-3391
Mailing Address - Fax:
Practice Address - Street 1:1209 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-6342
Practice Address - Country:US
Practice Address - Phone:662-335-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06972174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0013892Medicaid
MS0013892Medicaid