Provider Demographics
NPI:1487753562
Name:LADNER, MARK EDMUND (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDMUND
Last Name:LADNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:419 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4176
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-368-3904
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-368-3904
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS136512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116511Medicaid
MS04507528Medicaid
MS480302YJ5DMedicare PIN
MS04507528Medicaid
G26932Medicare UPIN