Provider Demographics
NPI:1609883446
Name:BELLAN, JOHN A JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:BELLAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:STE 104
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-969-6404
Practice Address - Fax:601-973-4541
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16704207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121619Medicaid
MS$$$$$$$$$BOtherBCBS
753068151OtherUHC
MS00121619Medicaid
753068151016OtherTRICARE
753068151OtherMPCN
753068151Other1ST CHOICE
753068151OtherMPCN
H10818Medicare UPIN
753068151OtherMHP