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General NPI Number Information
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NPI Number | 1477643732
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Entity Type | Organization
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Legal Business Name | DESOTO PRIMARY CARE CLINIC, PLLC
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Dates
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Enumeration Date | 10/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6942 AUTUMN OAKS DR
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-9379
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Country | US
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Telephone | 901-517-9171
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Fax |
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Provider Business Mailing Address
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Address Line | 6942 AUTUMN OAKS DR
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-9379
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Country | US
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Telephone | 901-517-9171
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Fax |
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Authorized Official
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Title or Position | SOLE OWNER
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Name | DR. LAJU A. KUMAR
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Credential | M.D.
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Telephone | 901-517-9171
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 18277
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License Number State | MS
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