Provider Demographics
NPI:1013173590
Name:DOUGLAS, LAURIE EVANS (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:EVANS
Last Name:DOUGLAS
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1700
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:301 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7233
Practice Address - Country:US
Practice Address - Phone:601-261-1700
Practice Address - Fax:601-288-8290
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23948207RH0003X
NC2014-00894207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00324314Medicaid
NC10131735900OtherTRICARE
NC10131735900Medicaid
NC187RGOtherBCBS
NC10131735900OtherUHC
NCQ94015OtherSC MEDICAID
NC10131735900OtherUHC
NC10131735900Medicaid