Provider Demographics
NPI:1114923794
Name:DUCKETT, LAURIE ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ANN
Last Name:DUCKETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 E 13TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4431
Mailing Address - Country:US
Mailing Address - Phone:918-599-8200
Mailing Address - Fax:918-579-2559
Practice Address - Street 1:1809 E 13TH ST STE 400
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4431
Practice Address - Country:US
Practice Address - Phone:918-599-8200
Practice Address - Fax:918-579-2559
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28602086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100136020BMedicaid
OK800522396Medicare PIN
248432701Medicare PIN