Healthcare Provider Details

I. General information

NPI: 1255755385
Provider Name (Legal Business Name): LAUREL OBSTETRICS AND GYNECOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 W 1ST ST SUITE 2
LAUREL MS
39440-4357
US

IV. Provider business mailing address

PO BOX 2998
LAUREL MS
39442-2998
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-9904
  • Fax: 601-649-9944
Mailing address:
  • Phone: 601-649-9904
  • Fax: 601-649-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13169
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT ALAN DESANTIS
Title or Position: PRESIDENT/OWNER/PHYSICIAN
Credential: M.D.
Phone: 601-649-9904