Provider Demographics
NPI:1790049120
Name:BRENTS, MELISSA JODI (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:JODI
Last Name:BRENTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3780
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3780
Mailing Address - Country:US
Mailing Address - Phone:601-483-8300
Mailing Address - Fax:601-484-7776
Practice Address - Street 1:1512 20TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4124
Practice Address - Country:US
Practice Address - Phone:601-483-8300
Practice Address - Fax:601-484-7776
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24885207ZP0102X
MST-2537207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST-2537OtherTEMPORARY STATE MEDICAL LICENSE