Provider Demographics
NPI:1346745775
Name:TIEDEMANN, LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:TIEDEMANN
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 1:825 E GATE BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2136
Mailing Address - Country:US
Mailing Address - Phone:516-804-5200
Mailing Address - Fax:516-766-3714
Practice Address - Street 1:1375 KINGS HWY STE 301
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5396
Practice Address - Country:US
Practice Address - Phone:203-366-8000
Practice Address - Fax:203-330-4598
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD477351207W00000X
NY323382207W00000X, 207WX0200X
CT75075207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery