Provider Demographics
NPI:1609984376
Name:BLACK, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BLACK
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:V. B. HARRISON STUDENT HEALTH
Mailing Address - Street 2:P.O. BOX 1848
Mailing Address - City:UNIVERSITY
Mailing Address - State:MS
Mailing Address - Zip Code:38677
Mailing Address - Country:US
Mailing Address - Phone:662-915-7274
Mailing Address - Fax:662-915-5292
Practice Address - Street 1:V. B. HARRISON STUDENT HEALTH
Practice Address - Street 2:REBEL DRIVE
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-7274
Practice Address - Fax:662-915-5292
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS162792084P0800X
TNM00143432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry