Provider Demographics
NPI:1336155399
Name:BARHAM, BROOKS (MD)
Entity Type:Individual
Prefix:
First Name:BROOKS
Middle Name:
Last Name:BARHAM
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:PO BOX 4710
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4710
Mailing Address - Country:US
Mailing Address - Phone:601-936-0494
Mailing Address - Fax:
Practice Address - Street 1:1030 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9553
Practice Address - Country:US
Practice Address - Phone:601-936-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS175222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08423212Medicaid
MS300001022Medicare ID - Type UnspecifiedMS MEDICARE
I05010Medicare UPIN