Provider Demographics
NPI:1477647287
Name:BADGLEY, LAURENCE EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:EUGENE
Last Name:BADGLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 HARRISON AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501
Mailing Address - Country:US
Mailing Address - Phone:707-441-2113
Mailing Address - Fax:707-444-0920
Practice Address - Street 1:2504 HARRISON AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-441-2113
Practice Address - Fax:707-444-0920
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2385207Q00000X
CAG18042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53963FMedicaid
CA943366913OtherCORPORATION TAX ID #
CAA90467Medicare UPIN
CA943366913OtherCORPORATION TAX ID #
CA553963Medicare ID - Type UnspecifiedRHC MEDICARE #