Healthcare Provider Details

I. General information

NPI: 1548354830
Provider Name (Legal Business Name): JIRAPUN LAIPRASERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST WOODROW WILLSON DRIVE
JACKSON MS
39216
US

IV. Provider business mailing address

761 RICE ROAD, APT # 519
RIDGELAND MS
39157
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4472
  • Fax:
Mailing address:
  • Phone: 601-605-9704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number33825
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: