Provider Demographics
NPI:1093726226
Name:MOCK, JAMES NELSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:NELSON
Last Name:MOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:205 S HIGHLAND WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-3362
Mailing Address - Country:US
Mailing Address - Phone:843-457-4747
Mailing Address - Fax:843-497-6405
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-457-0469
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036082903207P00000X
SC16733207P00000X
TN62661207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC167330Medicaid
SC167330Medicaid
F32984Medicare UPIN