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General NPI Number Information
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NPI Number | 1013228329
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Entity Type | Individual
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Provider Name | JUSTIN BLAKE DANIELS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/01/2010
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Last Update Date | 06/23/2013
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Provider Practice Location Address
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Address Line | 103 BRIGHTON LN APT/SUITE
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City | RIDGELAND
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State | MS
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Zip | 39157-8775
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Country | US
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Telephone | 601-421-9943
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Fax |
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Provider Business Mailing Address
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Address Line | 103 BRIGHTON LN APT/SUITE
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City | RIDGELAND
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State | MS
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Zip | 39157-8775
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Country | US
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Telephone | 601-421-9943
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | T-2302
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 21838
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License Number State | MS
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