Provider Demographics
NPI:1104853936
Name:HUBACEK, LAWRENCE JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:JEFFREY
Last Name:HUBACEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23457
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3457
Mailing Address - Country:US
Mailing Address - Phone:601-200-6175
Mailing Address - Fax:601-200-2020
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-6175
Practice Address - Fax:601-200-2020
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13184207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114632Medicaid
MS09014778Medicaid
MS09014778Medicaid
MSE94295Medicare UPIN
MSC02387Medicare PIN