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General NPI Number Information
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NPI Number | 1851585004
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Entity Type | Individual
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Provider Name | DEDRI MARKITA IVORY M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/30/2007
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Last Update Date | 01/13/2017
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Provider Practice Location Address
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Address Line | 3510 PEMBERTON SQUARE BLVD
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City | VICKSBURG
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State | MS
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Zip | 39180-5506
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Country | US
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Telephone | 601-501-6991
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Fax | 601-501-6987
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Provider Business Mailing Address
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Address Line | 3510 PEMBERTON SQUARE BLVD
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City | VICKSBURG
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State | MS
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Zip | 39180-5506
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Country | US
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Telephone | 601-501-6991
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Fax | 601-501-6987
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 21520
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 2009009253
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 57.011968
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License Number State | OH
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