Provider Demographics
NPI:1184823551
Name:LANEY, CHARLES ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLEN
Last Name:LANEY
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 1:2209 JEFFERSON DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5221
Mailing Address - Country:US
Mailing Address - Phone:662-281-1115
Mailing Address - Fax:662-281-1113
Practice Address - Street 1:2209 JEFFERSON DAVIS DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5221
Practice Address - Country:US
Practice Address - Phone:662-281-1115
Practice Address - Fax:662-281-1113
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22587174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07425565Medicaid