Provider Demographics
NPI:1164473799
Name:WALTRIP, LAURA SUE (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUE
Last Name:WALTRIP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E 41ST ST STE 925
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-4856
Mailing Address - Country:US
Mailing Address - Phone:512-978-9940
Mailing Address - Fax:512-901-9702
Practice Address - Street 1:1000 E 41ST ST STE 925
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-4856
Practice Address - Country:US
Practice Address - Phone:512-978-9940
Practice Address - Fax:512-901-9702
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6687207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046316801Medicaid
TX136668408Medicaid
TX88047NMedicare PIN
TXE13752Medicare UPIN
TX8857K4Medicare PIN
TX930102944Medicare PIN