Provider Demographics
NPI:1477625614
Name:LAMBUTH, BRUCE W (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:LAMBUTH
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 23996
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3996
Mailing Address - Country:US
Mailing Address - Phone:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:SUITE 208
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:601-353-4414
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013221Medicaid
MS110001010Medicare PIN
MS00013221Medicaid