Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RH0003X | Hematology & Oncology | 23948 | MS |
NPI | 1013173590 |
---|---|
Provider Name | Laurie Evans Douglas |
First Address | Hattiesburg, MS 39401-7246 |
Second Address | Hattiesburg, MS 39401-7233 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2008 |
Last Update Date | 09/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00324314 | (05) | MS |
10131735900 | (05) | NC |
10131735900 | TRICARE (01) | NC |
10131735900 | UHC (01) | NC |
187RG | BCBS (01) | NC |
Q94015 | SC MEDICAID (01) | NC |