Provider Demographics
NPI:1225079825
Name:BLACK, JOHN LARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LARRY
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:LARRY
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4364 HWY 51 SOUTH
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4364 HWY 51 SOUTH
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2534
Practice Address - Country:US
Practice Address - Phone:662-562-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11410207R00000X
MS8543207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4047712Medicaid
MS09015649Medicaid
MSP00396797OtherRAILROAD MEDICARE
MS080003405Medicare PIN
TN4047712Medicaid