Provider Demographics
NPI:1083663876
Name:BARKSDALE, BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:BARKSDALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5687
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF MEDICINE/DIVISION OF CARDIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5687
Practice Address - Fax:601-984-5638
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06380207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115734Medicaid
MSP00615907OtherRAILROAD
MS060021371OtherRAILROAD MEDICARE
LA1587451Medicaid
LA1587451Medicaid
MSP01118787Medicare PIN
MS335488YKDBMedicare PIN
MSP00615907OtherRAILROAD
MS302I065853Medicare PIN
MS00115734Medicaid