Provider Demographics
NPI:1689678674
Name:BRAND, JACK W JR (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:BRAND
Suffix:JR
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 1:1720A MEDICAL PARK DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2129
Mailing Address - Country:US
Mailing Address - Phone:228-392-7429
Mailing Address - Fax:228-396-3830
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUITE 340
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-392-7429
Practice Address - Fax:228-396-3830
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL11555207RC0000X
MS10246207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
C02478OtherGROUP MEDICARE
MS1194874222OtherGROUP NPI
MS05025093Medicaid
MS05025093Medicaid
H22338Medicare UPIN