Provider Demographics
NPI:1073682035
Name:RENFROE, DOYLE LAND (M D)
Entity type:Individual
Prefix:
First Name:DOYLE
Middle Name:LAND
Last Name:RENFROE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-1013
Mailing Address - Country:US
Mailing Address - Phone:662-234-1448
Mailing Address - Fax:662-234-1103
Practice Address - Street 1:1201 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5327
Practice Address - Country:US
Practice Address - Phone:662-234-1448
Practice Address - Fax:662-234-1103
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13909208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120826Medicaid
MS340000273Medicare ID - Type Unspecified
MS00120826Medicaid