Provider Demographics
NPI:1366003105
Name:WALDRUP, REBECCA ANNE (DO)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:WALDRUP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 HANSHAW RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-9458
Mailing Address - Country:US
Mailing Address - Phone:319-784-8079
Mailing Address - Fax:
Practice Address - Street 1:KEESLER AIR FORCE BASE MEDICAL CENTER
Practice Address - Street 2:101 FISHER ST
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534
Practice Address - Country:US
Practice Address - Phone:228-376-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.015002207P00000X
390200000X
MS32648207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34.015002OtherOHIO MEDICAL LICENSE
MS32648OtherMISSISSIPPI MEDICAL LICENSE