Provider Demographics
NPI:1447365606
Name:MORAN, OLIVIA D (MD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:D
Last Name:MORAN
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 1:84 LAIRD BRINSON RD
Mailing Address - Street 2:
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-4237
Mailing Address - Country:US
Mailing Address - Phone:601-792-4079
Mailing Address - Fax:601-792-4079
Practice Address - Street 1:84 LAIRD BRINSON RD
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-4237
Practice Address - Country:US
Practice Address - Phone:601-792-4079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1558961OtherAMERICAN ADMIN GROUP
MS00019906Medicaid
MS080014942OtherRAILROAD MEDICARE
MS00019906Medicaid
MS080014942OtherRAILROAD MEDICARE