Provider Demographics
NPI:1255755385
Name:LAUREL OBSTETRICS AND GYNECOLOGY PA
Entity type:Organization
Organization Name:LAUREL OBSTETRICS AND GYNECOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DESANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-649-9904
Mailing Address - Street 1:PO BOX 2998
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39442-2998
Mailing Address - Country:US
Mailing Address - Phone:601-649-9904
Mailing Address - Fax:601-649-9944
Practice Address - Street 1:1104 W 1ST ST
Practice Address - Street 2:SUITE 2
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4357
Practice Address - Country:US
Practice Address - Phone:601-649-9904
Practice Address - Fax:601-649-9944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13169207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty