Healthcare Provider Details

I. General information

NPI: 1790049120
Provider Name (Legal Business Name): MELISSA JODI BRENTS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 20TH AVE
MERIDIAN MS
39301-4124
US

IV. Provider business mailing address

PO BOX 3780
TUPELO MS
38803-3780
US

V. Phone/Fax

Practice location:
  • Phone: 601-483-8300
  • Fax: 601-484-7776
Mailing address:
  • Phone: 601-483-8300
  • Fax: 601-484-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number24885
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT-2537
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: