Basic Information
| Provider Information | |||||||||
| NPI: | 1710502661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAUREL PLASTIC SURGERY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 W 10TH ST | ||||||||
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| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394402538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017050078 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1410 JEFFERSON ST | ||||||||
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| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394404243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014257522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | NASAJPOUR | ||||||||
| AuthorizedOfficialFirstName: | HOSSEIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6015805076 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0200X | N | 193200000X MULTI-SPECIALTY GROUP | 2086S0122X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.