Provider Demographics
NPI:1104919513
Name:YOUNG, LAURA P (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:P
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:P
Other - Last Name:FOWLKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2301 S LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5373
Mailing Address - Country:US
Mailing Address - Phone:662-232-8568
Mailing Address - Fax:662-513-1450
Practice Address - Street 1:2301 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5373
Practice Address - Country:US
Practice Address - Phone:662-232-8568
Practice Address - Fax:662-513-1450
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14981207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS36-4373044OtherEMPLOYER ID #
MS116108Medicaid
MS116108Medicaid
MS60000407Medicare PIN
MSG16651Medicare UPIN