Provider Demographics
NPI:1700034451
Name:YOUNG-GAYLOR, LAFARRA DEMETRIC (MD)
Entity Type:Individual
Prefix:DR
First Name:LAFARRA
Middle Name:DEMETRIC
Last Name:YOUNG-GAYLOR
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 1:442 ASHTREE LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6703
Mailing Address - Country:US
Mailing Address - Phone:601-405-4163
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-07
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20180207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07189228Medicaid
AL156938Medicaid
MS07189228Medicaid
MS302I228874Medicare PIN
MSP00882944Medicare PIN