Provider Demographics
NPI:1063496545
Name:LAURIE, JACK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALAN
Last Name:LAURIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-782-5110
Mailing Address - Fax:951-274-0403
Practice Address - Street 1:6405 DAY ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0901
Practice Address - Country:US
Practice Address - Phone:951-697-5430
Practice Address - Fax:951-697-5488
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43352208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ92058ZOtherGROUP SITE LOCATION
OOG433520Medicare ID - Type Unspecified
ZZZ92058ZOtherGROUP SITE LOCATION