Provider Demographics
NPI:1124017975
Name:DOUGLASS, LAURIE M (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:M
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURIE
Other - Middle Name:M
Other - Last Name:MCGONIGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST
Practice Address - Street 2:SHAPIRO 8
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-414-4841
Practice Address - Fax:617-414-4502
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159823208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110061538AMedicaid
MAUX4967Medicare PIN
MA110061538AMedicaid