Provider Demographics
NPI:1104098110
Name:WITHERS, LAURA TERESA (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:TERESA
Last Name:WITHERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:TERESA
Other - Last Name:GIDEON WITHERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3500 S. SCOTT BLVD
Mailing Address - Street 2:12B
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203
Mailing Address - Country:US
Mailing Address - Phone:917-650-5408
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:DDEPARTMENT OF FAMILT MEDICINE
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-1000
Practice Address - Country:US
Practice Address - Phone:573-884-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME002800501208600000X
MO2025045730207QH0002X
WA6023305432086S0127X, 208600000X
FLME1023322086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAX172ZMedicare PIN