Provider Demographics
NPI:1326314881
Name:LAURIE BOQUET DORY, M.D.P.A.
Entity Type:Organization
Organization Name:LAURIE BOQUET DORY, M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:BOQUET
Authorized Official - Last Name:DORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-332-5585
Mailing Address - Street 1:901 TRAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3137
Mailing Address - Country:US
Mailing Address - Phone:817-332-5585
Mailing Address - Fax:817-332-5377
Practice Address - Street 1:901 TRAVIS AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3137
Practice Address - Country:US
Practice Address - Phone:817-332-5585
Practice Address - Fax:817-332-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4779174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1460289-01Medicaid
TX7540001OtherAETNA
TX180041477OtherRAILROAD MEDICARE
TX2075692OtherCIGNA
TX3378225OtherBCBS BLUE LINK
TX0076EQOtherBCBS
TX7540001OtherAETNA
TX1460289-01Medicaid