Provider Demographics
NPI:1043395890
Name:MAVITY, LAURA KELLY (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KELLY
Last Name:MAVITY
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 1:2500 NE NEFF RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6015
Mailing Address - Country:US
Mailing Address - Phone:541-706-5880
Mailing Address - Fax:
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:ST. CHARLES MEDICAL CENTER - BEND
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-706-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25707207R00000X, 207RH0002X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine