Provider Demographics
NPI:1639117245
Name:MEHRLE, ROBERT K JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
Last Name:MEHRLE
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 1:1325 E FORTIFICATION ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2442
Mailing Address - Country:US
Mailing Address - Phone:601-354-4488
Mailing Address - Fax:601-960-4586
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-354-4488
Practice Address - Fax:601-960-4586
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17298207XS0114X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01227851Medicaid
MSP00325234OtherRROAD MEDICARE
MS52I200004OtherMEDICARE PTAN
MS512G700003OtherUP MEDICARE
MS200000479OtherMEDICARE
MSP00645611OtherRR PTAN
MS200000479OtherMEDICARE