Provider Demographics
NPI:1417954017
Name:THEIS, LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:THEIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:KARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:821 E CHAPEL ST STE 103
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4618
Mailing Address - Country:US
Mailing Address - Phone:805-310-5330
Mailing Address - Fax:805-310-5339
Practice Address - Street 1:821 E CHAPEL ST STE 103
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4618
Practice Address - Country:US
Practice Address - Phone:805-310-5330
Practice Address - Fax:805-310-5339
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA68947CMedicare PIN
H10466Medicare UPIN
CAWA68947BMedicare PIN