Provider Demographics
NPI:1053374041
Name:WARE, PAUL DEREK (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DEREK
Last Name:WARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1200
Mailing Address - Fax:228-575-1205
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-575-1200
Practice Address - Fax:228-575-1205
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025475174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1579009Medicaid
LAH75344Medicare UPIN
LA4E730Medicare PIN