Provider Demographics
NPI:1619020401
Name:DODD, JOHN EDWIN JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWIN
Last Name:DODD
Suffix:JR
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 1:2470 FLOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9019
Mailing Address - Country:US
Mailing Address - Phone:601-664-1213
Mailing Address - Fax:601-932-8869
Practice Address - Street 1:2470 FLOWOOD DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9019
Practice Address - Country:US
Practice Address - Phone:601-664-1213
Practice Address - Fax:601-932-8869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10764207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018622Medicaid
MS00018622Medicaid