Provider Demographics
NPI:1699394098
Name:MILTON, LARRY ETHAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ETHAN
Last Name:MILTON
Suffix:
Gender:M
Credentials:DPM
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 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-425-7550
Mailing Address - Fax:
Practice Address - Street 1:1002 JEFFERSON ST.
Practice Address - Street 2:SUITE 400
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440
Practice Address - Country:US
Practice Address - Phone:601-649-7802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
211D00000X
MS80249213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric