Provider Demographics
NPI:1417930900
Name:DORY, LAURIE BOQUET (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:BOQUET
Last Name:DORY
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 1:901 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4779174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3378225OtherBCBS BLUE LINK NUMBER
TX146028901Medicaid
TX0076EQOtherBCBS NUMBER
TX7540001OtherAETNA
TX7540001OtherAETNA
TX146028901Medicaid
TX00831LMedicare ID - Type Unspecified