Basic Information
| Provider Information | |||||||||
| NPI: | 1013173590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | EVANS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012611700 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012611700 | ||||||||
| FaxNumber: | 6012888290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 23948 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00324314 | 05 | MS | MEDICAID | 10131735900 | 01 | NC | TRICARE | OTHER | 10131735900 | 05 | NC | MEDICAID | 187RG | 01 | NC | BCBS | OTHER | 10131735900 | 01 | NC | UHC | OTHER | Q94015 | 01 | NC | SC MEDICAID | OTHER |