Provider Demographics
NPI:1215049929
Name:CALCOTE, CLAY BRODERS (MD)
Entity type:Individual
Prefix:DR
First Name:CLAY
Middle Name:BRODERS
Last Name:CALCOTE
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 1:6231 NORTHLAKE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2124
Mailing Address - Country:US
Mailing Address - Phone:601-957-0096
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-364-1342
Practice Address - Fax:601-364-1392
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14411207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology