Healthcare Provider Details

I. General information

NPI: 1619607066
Provider Name (Legal Business Name): LEA MARIE TRUSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
KEESLER AFB MS
39534-2508
US

IV. Provider business mailing address

1200 DEANA ST APT K203
OCEAN SPRINGS MS
39564-0015
US

V. Phone/Fax

Practice location:
  • Phone: 228-376-2664
  • Fax:
Mailing address:
  • Phone: 603-498-9012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number35.149194
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57.253672
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35.149194
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: