Provider Demographics
NPI:1417584020
Name:WILLARD, LAURA FAYE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:FAYE
Last Name:WILLARD
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 1:177 FT. WASHINGTON AVE.
Mailing Address - Street 2:7GS-313
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-305-3038
Mailing Address - Fax:
Practice Address - Street 1:177 FT. WASHINGTON AVE.
Practice Address - Street 2:7GS-313
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program