Basic Information
| Provider Information | |||||||||
| NPI: | 1447279526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRIDDLE | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | JEFFERSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 315 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019846426 | ||||||||
| FaxNumber: | 6019846439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 13166 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | 13166 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07076260 | 05 | MS | MEDICAID | P01212522 | 01 | MS | RAILROAD MEDICARE | OTHER | 13166 | 01 | MS | MEDICAL LICENSE NUMBER | OTHER |