Healthcare Provider Details

I. General information

NPI: 1467686428
Provider Name (Legal Business Name): SIRA MARY DUSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 11/23/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

22 S GREENE ST # S10B00
BALTIMORE MD
21201-1544
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7272
  • Fax: 901-545-8292
Mailing address:
  • Phone: 410-328-5840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD042335
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number70074
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD81874
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: