Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 21838 | MS |
Y | 207P00000X | Emergency Physician | T-2302 | MS |
NPI | 1013228329 |
---|---|
Provider Name | Dr. Justin Blake Daniels |
First Address | Ridgeland, MS 39157-8775 |
Second Address | Ridgeland, MS 39157-8775 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2010 |
Last Update Date | 23/06/2013 |