Provider Demographics
NPI:1457446247
Name:STITLE, LAURA T (MD)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:T
Last Name:STITLE
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 1:53 SOUTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143
Mailing Address - Country:US
Mailing Address - Phone:317-889-7546
Mailing Address - Fax:317-889-2482
Practice Address - Street 1:53 SOUTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-889-7546
Practice Address - Fax:317-889-2482
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056989A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000306309OtherANTHEM
7475840OtherCIGNA
IN7268449OtherAETNA
A83764Medicare UPIN
IN000000306309OtherANTHEM