Healthcare Provider Details

I. General information

NPI: 1982961728
Provider Name (Legal Business Name): LAURA REBECCA DAILY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA REBECCA DAILY MD

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST STE G07
JACKSON MS
39202-1651
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-3238
  • Fax: 601-968-3237
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberE-90608
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number54021
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number24393
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: