Healthcare Provider Details

I. General information

NPI: 1124180567
Provider Name (Legal Business Name): JOHN D BELKNAP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5606 OLD CANTON RD
JACKSON MS
39211-4217
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-3333
  • Fax: 601-957-3335
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19395
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: