Provider Demographics
NPI:1508029083
Name:BLACK, JASON L (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 BIENVILLE BLVD
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4361
Mailing Address - Country:US
Mailing Address - Phone:228-818-1111
Mailing Address - Fax:
Practice Address - Street 1:3109 BIENVILLE BLVD
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4361
Practice Address - Country:US
Practice Address - Phone:228-818-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-06
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2070207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS20838OtherPERMANENT LICENSE NUMBER