Provider Demographics
NPI:1003889783
Name:FORD, LAURA JUNE (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JUNE
Last Name:FORD
Suffix:
Gender:F
Credentials:DO
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 563
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-0563
Mailing Address - Country:US
Mailing Address - Phone:520-934-4624
Mailing Address - Fax:
Practice Address - Street 1:308B SPRING ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:TN
Practice Address - Zip Code:37058-3233
Practice Address - Country:US
Practice Address - Phone:520-934-4624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-11
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013243208000000X
AZ0091292080P0006X
TN00000045392080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002198AMedicaid
GA100002198BMedicaid
FL2193666-00Medicaid
FLP68692Medicare UPIN
GA100002198BMedicaid
FL970028147Medicare PIN