Provider Demographics
NPI:1225156672
Name:DISTEL, LAURA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:M
Last Name:DISTEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:185 WADSWORTH RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8330
Mailing Address - Country:US
Mailing Address - Phone:330-331-7106
Mailing Address - Fax:330-331-7556
Practice Address - Street 1:185 WADSWORTH RD
Practice Address - Street 2:SUITE D
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8330
Practice Address - Country:US
Practice Address - Phone:330-331-7106
Practice Address - Fax:330-331-7556
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35093592207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3090926Medicaid
OH4305471Medicare PIN