Provider Demographics
NPI:1508220252
Name:REGAN, CORNELIUS E JR (MD)
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:E
Last Name:REGAN
Suffix:JR
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 1:109 MILLSAPS DR STE B
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1587
Mailing Address - Country:US
Mailing Address - Phone:601-255-0736
Mailing Address - Fax:
Practice Address - Street 1:109 MILLSAPS DR STE B
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1587
Practice Address - Country:US
Practice Address - Phone:601-255-0736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN60893207W00000X
MS27509207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000559073Medicaid