Healthcare Provider Details

I. General information

NPI: 1093109316
Provider Name (Legal Business Name): JUSTIN M. LAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 MONTGOMERY ST STE D
MADISON MS
39110-1118
US

IV. Provider business mailing address

161 MONTGOMERY ST STE D
MADISON MS
39110-1118
US

V. Phone/Fax

Practice location:
  • Phone: 769-300-5200
  • Fax: 601-623-4300
Mailing address:
  • Phone: 769-300-5220
  • Fax: 601-623-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25783
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: