Provider Demographics
NPI:1164512711
Name:LYCKHOLM, LAUREL J (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:J
Last Name:LYCKHOLM
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 1:200 HAWKINS DR
Mailing Address - Street 2:C21-GH
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-467-5346
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:C21-GH
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-467-5346
Practice Address - Fax:319-353-8383
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27102207RH0003X
VA0101053211207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6028888Medicaid
E10485Medicare UPIN
110006001Medicare ID - Type Unspecified