Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 23810 | MS |
N | 207ND0101X | MOHS-Micrographic Surgeon | 23810 | MS |
N | 207NS0135X | Procedural Dermatology | 23810 | MS |
NPI | 1215249131 |
---|---|
Provider Name | Dr. Bradley Noel Greenhaw |
First Address | Tupelo, MS 38801-6347 |
Second Address | Tupelo, MS 38801-6347 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2010 |
Last Update Date | 19/05/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T-2318 | TEMPORART MS MEDICAL LICENSE NUMBER (01) | MS |