Provider Demographics
NPI:1861470627
Name:CRECELIUS, LAURA JANE (MD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JANE
Last Name:CRECELIUS
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 1:3301 TININ DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9054
Mailing Address - Country:US
Mailing Address - Phone:662-665-9111
Mailing Address - Fax:662-665-9118
Practice Address - Street 1:3301 TININ DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9054
Practice Address - Country:US
Practice Address - Phone:662-665-9111
Practice Address - Fax:662-665-9118
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117464Medicaid
MSG31135Medicare UPIN
MS160000467Medicare ID - Type Unspecified