Provider Demographics
NPI:1912933672
Name:TEAL CLEMENT, LARA J (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:J
Last Name:TEAL CLEMENT
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 1:200 AMITY LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7941
Mailing Address - Country:US
Mailing Address - Phone:601-206-0901
Mailing Address - Fax:888-240-6288
Practice Address - Street 1:MAGNOLIA SENIOR CARE
Practice Address - Street 2:3701 PETER QUINN DR
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-206-0901
Practice Address - Fax:888-240-6288
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122664Medicaid
LA1436721Medicaid
MS7587143OtherAETNA
MS7587143OtherAETNA
MSP00138918Medicare PIN
LA1436721Medicaid
MS7587143OtherAETNA