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General NPI Number Information
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NPI Number | 1144418609
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Entity Type | Organization
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Legal Business Name | LAFAYETTE PEDIATRIC CLINIC
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Dates
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Enumeration Date | 10/10/2007
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Last Update Date | 03/17/2010
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Provider Practice Location Address
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Address Line | 2166 S LAMAR BLVD
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City | OXFORD
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State | MS
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Zip | 38655-5224
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Country | US
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Telephone | 662-236-3939
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Fax | 662-236-3924
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Provider Business Mailing Address
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Address Line | 2166 S LAMAR BLVD
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City | OXFORD
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State | MS
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Zip | 38655-5224
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Country | US
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Telephone | 662-236-3939
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Fax | 662-236-3924
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Authorized Official
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Title or Position | OWNER
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Name | TANYA JEAN FITTS
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Credential | M.D.
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Telephone | 662-236-3939
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 17111
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License Number State | MS
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