Provider Demographics
NPI:1124388129
Name:BLACK, LAURA CELESTE (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CELESTE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:CELESTE
Other - Last Name:DEPOULI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:17 VIRGINIA AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4406
Mailing Address - Country:US
Mailing Address - Phone:401-443-4992
Mailing Address - Fax:401-784-4902
Practice Address - Street 1:336 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117
Practice Address - Country:US
Practice Address - Phone:860-232-4891
Practice Address - Fax:860-236-1016
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14897207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine