Healthcare Provider Details

I. General information

NPI: 1225079825
Provider Name (Legal Business Name): JOHN LARRY BLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: J LARRY BLACK M.D.

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4364 HWY 51 SOUTH
SENATOBIA MS
38668-2534
US

IV. Provider business mailing address

4364 HWY 51 SOUTH
SENATOBIA MS
38668-2534
US

V. Phone/Fax

Practice location:
  • Phone: 662-562-6026
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11410
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8543
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number8543
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: