Healthcare Provider Details

I. General information

NPI: 1538059969
Provider Name (Legal Business Name): LESLEY MORGAN BIRDSONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 CENTRAL AVE
COLDWATER MS
38618-3915
US

IV. Provider business mailing address

4500 ABERTON DR
SOUTHAVEN MS
38672-7174
US

V. Phone/Fax

Practice location:
  • Phone: 662-622-7011
  • Fax:
Mailing address:
  • Phone: 662-501-6898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number907568
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: