Healthcare Provider Details

I. General information

NPI: 1083729362
Provider Name (Legal Business Name): LAWRENCE LEE CRESWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5170
  • Fax: 601-984-5198
Mailing address:
  • Phone: 601-984-5170
  • Fax: 601-984-5198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number17992
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: