Healthcare Provider Details

I. General information

NPI: 1831119676
Provider Name (Legal Business Name): LAUREL A TAIT DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HIGHWAY 62 W
SALEM AR
72576-8059
US

IV. Provider business mailing address

3880 MAJESTIC OAKS DR
OXFORD MS
38655-8143
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2015
  • Fax: 870-895-2164
Mailing address:
  • Phone: 662-236-7070
  • Fax: 662-236-7078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberMO00556
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: