Provider Demographics
NPI:1154354603
Name:DUDLEY, SHINITA REED (MD)
Entity type:Individual
Prefix:
First Name:SHINITA
Middle Name:REED
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHINTA
Other - Middle Name:YEWONDE
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:507 SPRINGRIDGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5628
Mailing Address - Country:US
Mailing Address - Phone:601-708-1414
Mailing Address - Fax:601-708-1415
Practice Address - Street 1:507 SPRINGRIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5628
Practice Address - Country:US
Practice Address - Phone:601-708-1414
Practice Address - Fax:601-708-1415
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
770899OtherADVANTRA FREEDOM
MS07033864Medicaid
MS07033864Medicaid
MS512I080001Medicare PIN
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