Provider Demographics
NPI:1912036823
Name:BROCK, JAMES MURRAY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MURRAY
Last Name:BROCK
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 1:136 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3620
Mailing Address - Country:US
Mailing Address - Phone:601-684-3210
Mailing Address - Fax:601-684-3319
Practice Address - Street 1:136 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3620
Practice Address - Country:US
Practice Address - Phone:601-684-3210
Practice Address - Fax:601-684-3319
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07285207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115075Medicaid
MS00115075Medicaid
MS$$$$$$$$$AOtherBLUE CROSS BLUE SHIELD
MS070000080Medicare PIN
MS$$$$$$$$$AOtherSTATE OF MS CLAIMS ADMINISTRATOR