Provider Demographics
NPI:1265652531
Name:HARTWELL, LAUREL HICKOK (MD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:HICKOK
Last Name:HARTWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:ANN
Other - Last Name:HICKOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6048
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6048
Mailing Address - Country:US
Mailing Address - Phone:541-382-2811
Mailing Address - Fax:
Practice Address - Street 1:1501 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6051
Practice Address - Country:US
Practice Address - Phone:541-382-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD151664207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01357484OtherRAILROAD MEDICARE
OR12725068OtherCAQH
OR500624979Medicaid
ORP01357484OtherRAILROAD MEDICARE