Provider Demographics
NPI:1073624573
Name:BRAKER, LAURIE S (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:S
Last Name:BRAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:S
Other - Last Name:VANDYKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4294 LAUREL DR
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-8430
Practice Address - Country:US
Practice Address - Phone:616-374-7660
Practice Address - Fax:616-374-0270
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P18430Medicare ID - Type Unspecified
MI4301080130OtherSTATE LICENSE MI
MII31815Medicare UPIN
MI4765084Medicaid
MI0341044OtherBLUE CROSS BLUE SHIELD MI