Healthcare Provider Details

I. General information

NPI: 1144418609
Provider Name (Legal Business Name): LAFAYETTE PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 S LAMAR BLVD
OXFORD MS
38655-5224
US

IV. Provider business mailing address

2166 S LAMAR BLVD
OXFORD MS
38655-5224
US

V. Phone/Fax

Practice location:
  • Phone: 662-236-3939
  • Fax: 662-236-3924
Mailing address:
  • Phone: 662-236-3939
  • Fax: 662-236-3924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number17111
License Number StateMS

VIII. Authorized Official

Name: TANYA JEAN FITTS
Title or Position: OWNER
Credential: M.D.
Phone: 662-236-3939