Stephen D Sudderth, MD

Primary specialty

Surgery PhysicianTaxonomy code 208600000X

License

17597 Issued in MS

Practice address

188 YMCA PL
Vicksburg, MS 39183-3536

Phone

(601) 636-7222

Fax

(601) 636-0440

NPI assigned

Jun 28, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in MS

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• River City Dermatology and Aesthetics LLC

  • Dermatology Physician
  • Vicksburg, MS
  • NPI 1528812203
  NPD
• Vicksburg Clinic LLC

  • Infectious Disease Physician
  • Vicksburg, MS
  • NPI 1659307791

  Surgery

  NPD (past)
• Vicksburg Clinic LLC

  • Family Medicine Physician
  • Vicksburg, MS
  • NPI 1790711158
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151452800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1392940800000",
    "number": "1528096849",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "188 YMCA PL",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391833536",
            "telephone_number": "601-636-7222",
            "fax_number": "601-636-0440"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "188 YMCA PL",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391833536",
            "telephone_number": "601-636-7222",
            "fax_number": "601-636-0440"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUDDERTH",
        "first_name": "STEPHEN",
        "middle_name": "D",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-06-28",
        "last_updated": "2014-02-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "MS",
            "license": "17597",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00126115",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1986712",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sarah Stewart, PCHMT
• Richard M Stone Jr., CRNA
• Delta Katherine Stout, DMD
• Candace Strong, M.A., P-LPC
• Michelle Banks Strong
• Emmanuel Kofi Suka Jr Jr., PHARM. D
• Carol Sullivan
• Jayme Sullivan, LPC
• Christopher Sumrall
• Super Shots Mobile Flu Shot Clinic

• Surgery Physician in Vicksburg, MS
• Providers in Vicksburg, MS by specialty
• Surgery Physician in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.