Provider Demographics
NPI:1174545636
Name:SMELTER, LAURA E (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:SMELTER
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 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-8450
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-1215
Practice Address - Fax:817-927-6843
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200800950BMedicaid
INP00302491OtherR/R MEDICARE
IN200800590AMedicaid
IN200800950BMedicaid
INP00302491OtherR/R MEDICARE
IN223520OMedicare ID - Type UnspecifiedMIDDLEBURY SITE
IN738460XXXXMedicare PIN