Provider Demographics
NPI:1083647226
Name:HARTLEY, LAURENCE WILBUR (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:WILBUR
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1165 S DORA ST
Mailing Address - Street 2:SUITE G 2
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-8325
Mailing Address - Country:US
Mailing Address - Phone:707-463-5535
Mailing Address - Fax:707-463-0591
Practice Address - Street 1:1165 S DORA ST
Practice Address - Street 2:SUITE G 2
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-8325
Practice Address - Country:US
Practice Address - Phone:707-463-5535
Practice Address - Fax:707-463-0591
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25739207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A257391Medicaid
CA00A257390Medicare ID - Type Unspecified
CAA24555Medicare UPIN