Provider Demographics
NPI:1669672143
Name:LAUREL UROLOGY CLINIC PA
Entity Type:Organization
Organization Name:LAUREL UROLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WATKINS III
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-428-0438
Mailing Address - Street 1:PO BOX 2728
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39442-2728
Mailing Address - Country:US
Mailing Address - Phone:601-428-0438
Mailing Address - Fax:601-425-5553
Practice Address - Street 1:304 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440
Practice Address - Country:US
Practice Address - Phone:601-428-0438
Practice Address - Fax:601-425-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05031208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011830Medicaid