Healthcare Provider Details

I. General information

NPI: 1407052319
Provider Name (Legal Business Name): CENTRAL MISSISSIPPI FOOT SPECIALIST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SERVICE DR
BRANDON MS
39042-2401
US

IV. Provider business mailing address

103 SERVICE DR
BRANDON MS
39042-2401
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-4700
  • Fax: 601-824-4800
Mailing address:
  • Phone: 601-824-4700
  • Fax: 601-824-4800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number80160
License Number StateMS

VIII. Authorized Official

Name: LAWRENCE EDWARD TAMBURINO
Title or Position: DOCTOR OF PODIATRIC MEDICINE
Credential: D.P.M,
Phone: 601-824-4700