Provider Demographics
NPI:1326082397
Name:MIRE, BLANE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BLANE
Middle Name:A
Last Name:MIRE
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 1:209 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4707
Mailing Address - Country:US
Mailing Address - Phone:601-446-8599
Mailing Address - Fax:
Practice Address - Street 1:46 SERGEANT PRENTISS DR
Practice Address - Street 2:SUITE 300
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4725
Practice Address - Country:US
Practice Address - Phone:601-446-7343
Practice Address - Fax:601-445-0833
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119463Medicaid
MS110001724Medicare ID - Type Unspecified
MS00119463Medicaid