Provider Demographics
NPI:1760586002
Name:LORIA, PHILIP R JR (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
Last Name:LORIA
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 1:2204 JEFFERSON DAVIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655
Mailing Address - Country:US
Mailing Address - Phone:662-236-6850
Mailing Address - Fax:662-236-5010
Practice Address - Street 1:2204 JEFFERSON DAVIS DRIVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-236-6850
Practice Address - Fax:662-236-5010
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12732207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016031Medicaid
D79784Medicare UPIN
MS070000022Medicare ID - Type Unspecified