Healthcare Provider Details

I. General information

NPI: 1568041804
Provider Name (Legal Business Name): TAYLOR LUBAG JAHN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15024 MARTIN LUTHER KING JR BLVD
GULFPORT MS
39501-8306
US

IV. Provider business mailing address

2213 KELLY AVE
GULFPORT MS
39501-3305
US

V. Phone/Fax

Practice location:
  • Phone: 228-864-0003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33009
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: