Healthcare Provider Details

I. General information

NPI: 1285263376
Provider Name (Legal Business Name): COLE SHANE CRAIGHEAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

IV. Provider business mailing address

425 HIGHWAY 51 N
BROOKHAVEN MS
39601-2350
US

V. Phone/Fax

Practice location:
  • Phone: 318-450-0092
  • Fax: 601-748-7063
Mailing address:
  • Phone: 318-450-0092
  • Fax: 601-748-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35672
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: