Provider Demographics
NPI:1497843676
Name:SHROCK, WIRT FLETCHER JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WIRT
Middle Name:FLETCHER
Last Name:SHROCK
Suffix:JR
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 1:630 NORTHWEST AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:MS
Mailing Address - Zip Code:39063-3337
Mailing Address - Country:US
Mailing Address - Phone:662-653-3012
Mailing Address - Fax:662-653-6423
Practice Address - Street 1:630 NORTHWEST AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:MS
Practice Address - Zip Code:39063-3337
Practice Address - Country:US
Practice Address - Phone:662-653-3012
Practice Address - Fax:662-653-6423
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0011270Medicaid
MSB66187Medicare UPIN
MS080000342Medicare PIN