Provider Demographics
NPI:1508218504
Name:FROSSARD, BRENTLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENTLEY
Middle Name:
Last Name:FROSSARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 ALCORN DR
Mailing Address - Street 2:GRADUATE MEDICAL EDUCATION
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9321
Mailing Address - Country:US
Mailing Address - Phone:662-293-7686
Mailing Address - Fax:
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9321
Practice Address - Country:US
Practice Address - Phone:662-293-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-3118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine