Provider Demographics
NPI:1255311908
Name:CARRAVALLAH, LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:CARRAVALLAH
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 1:225 E 5TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1641
Mailing Address - Country:US
Mailing Address - Phone:810-406-4246
Mailing Address - Fax:810-424-6029
Practice Address - Street 1:5710 CLIO RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-1524
Practice Address - Country:US
Practice Address - Phone:810-787-4445
Practice Address - Fax:810-244-8901
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054994207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1386624278OtherGROUP NPI
MI4350553Medicaid
MI0B56065011Medicare ID - Type Unspecified
MIF71828Medicare UPIN