Provider Demographics
NPI:1164477394
Name:ALLEN, LAURA HALL (MD,)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:HALL
Last Name:ALLEN
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:PO BOX 24848
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4848
Mailing Address - Country:US
Mailing Address - Phone:336-238-1679
Mailing Address - Fax:336-713-6622
Practice Address - Street 1:107 W MEDICAL PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-6851
Practice Address - Country:US
Practice Address - Phone:336-238-1679
Practice Address - Fax:336-713-6622
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-005862085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00855346DMedicaid
NC5914906Medicaid
GA00855346EMedicaid
NC2075921Medicare PIN