Healthcare Provider Details

I. General information

NPI: 1801877139
Provider Name (Legal Business Name): BRAXTER P IRBY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513C BROOKMAN DR
BROOKHAVEN MS
39601-2326
US

IV. Provider business mailing address

513C BROOKMAN DR
BROOKHAVEN MS
39601-2326
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-3822
  • Fax: 601-835-4330
Mailing address:
  • Phone: 601-833-3822
  • Fax: 601-835-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number06205
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: