Provider Demographics
NPI:1275664732
Name:LAUDERDALE, REBECCA WALTERS (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:WALTERS
Last Name:LAUDERDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-296-2980
Mailing Address - Fax:601-579-5463
Practice Address - Street 1:1101 S 28TH AVE STE D
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-2610
Practice Address - Country:US
Practice Address - Phone:601-296-2980
Practice Address - Fax:601-296-2975
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19683207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01224050Medicaid
MS9445059OtherAETNA
P00436837OtherRAILROAD MEDICARE
MS01224050Medicaid