Provider Demographics
NPI:1346358579
Name:CLARKSTON, LAURIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:A
Last Name:CLARKSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:A
Other - Last Name:OHNESORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:816 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-1518
Practice Address - Country:US
Practice Address - Phone:417-269-2490
Practice Address - Fax:417-269-2492
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000154878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204998405Medicaid
128140OtherBLUE CROSS MO
H14920Medicare UPIN
MO204998405Medicaid
080158028Medicare PIN