Provider Demographics
NPI:1831119676
Name:TAIT, LAUREL A (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:A
Last Name:TAIT
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 MAJESTIC OAKS DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-8143
Mailing Address - Country:US
Mailing Address - Phone:662-236-7070
Mailing Address - Fax:662-236-7078
Practice Address - Street 1:106 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-8059
Practice Address - Country:US
Practice Address - Phone:870-895-2015
Practice Address - Fax:870-895-2164
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO00556213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO480005007OtherRAILROAD MEDICARE
MO12934038OtherBLUE CROSS BLUE SHIELD
MS02358739Medicaid
MO12934038OtherBLUE CROSS BLUE SHIELD
MS0006734Medicare PIN
MS0780300001Medicare NSC