Healthcare Provider Details

I. General information

NPI: 1720067994
Provider Name (Legal Business Name): JOHN C HANCOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

969 LAKELAND DR
JACKSON MS
39216-4606
US

V. Phone/Fax

Practice location:
  • Phone: 607-200-6762
  • Fax:
Mailing address:
  • Phone: 601-200-6762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number12120
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number12120
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: