Provider Demographics
NPI:1124405691
Name:BLACK, JOSHUA T (MD)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:T
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39760-1326
Mailing Address - Country:US
Mailing Address - Phone:662-615-2830
Mailing Address - Fax:662-615-2836
Practice Address - Street 1:107 BRANDON RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-615-3771
Practice Address - Fax:662-615-3775
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38401207Q00000X
MS25884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine