Healthcare Provider Details

I. General information

NPI: 1710502661
Provider Name (Legal Business Name): LAUREL PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 JEFFERSON ST
LAUREL MS
39440-4243
US

IV. Provider business mailing address

1923 W 10TH ST
LAUREL MS
39440-2538
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-7522
  • Fax:
Mailing address:
  • Phone: 601-705-0078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HOSSEIN NASAJPOUR
Title or Position: OWNER
Credential: MD
Phone: 601-580-5076