Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 21425 | MS |
N | 111NI0900X | Internist | 21425 | MS |
Y | 207RI0200X | Infectious Disease | 21425 | MS |
N | 208000000X | Pediatrician | 21425 | MS |
NPI | 1073742607 |
---|---|
Provider Name | Dr. James Benjamin Brock |
First Address | Jackson, MS 39216-4500 |
Second Address | Jackson, MS 39216-4500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2009 |
Last Update Date | 31/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03679540 | (05) | MS |
P01667060 | RAILROAD MEDICARE (01) | MS |