Healthcare Provider Details

I. General information

NPI: 1801398110
Provider Name (Legal Business Name): LIANETTE SOFIA LOZADA BADO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4742
US

IV. Provider business mailing address

PO BOX 947
LAS PIEDRAS PR
00771-0947
US

V. Phone/Fax

Practice location:
  • Phone: 662-772-3942
  • Fax:
Mailing address:
  • Phone: 787-245-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberT-6262
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: