Provider Demographics
NPI:1386685642
Name:HEIMBACK-GRAHAM, LAURA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LYNN
Last Name:HEIMBACK-GRAHAM
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:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:10330 N DALE MABRY HWY STE 190
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4404
Practice Address - Country:US
Practice Address - Phone:813-963-7788
Practice Address - Fax:813-443-8149
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112872208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000500480005OtherBC/BS
1211500OtherIHA
000500480004OtherBC/BS
FL0065758-00Medicaid
08047000068OtherFIDELIS
040426002037OtherFIDELIS
PA0019433420001Medicaid
NY00850591Medicaid
00010074902OtherUNIVERA
H77040Medicare UPIN
PA0019433420001Medicaid