Provider Demographics
NPI:1023029907
Name:WEATHERS, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WEATHERS
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-2812
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:MDC 15
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3603
Practice Address - Country:US
Practice Address - Phone:813-259-8700
Practice Address - Fax:813-250-2101
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58371208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056455900Medicaid
FL14374OtherBLUE CROSS BLUE SHIELD
FL14374VMedicare PIN
FL056455900Medicaid