Provider Demographics
NPI:1487674776
Name:DIMMICK, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DIMMICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:RAHAIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8649 AUTUMN GREEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9560
Mailing Address - Country:US
Mailing Address - Phone:904-476-6438
Mailing Address - Fax:
Practice Address - Street 1:820 PRUDENTIAL DR STE 713
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8209
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:904-346-0864
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073498207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000786871DMedicaid
FL44334OtherBCBS OF FLORIDA
FLP00138982OtherRAILROAD MEDICARE
FL254874700Medicaid
P00395758OtherRAILROAD MEDICARE
FL44334AMedicare ID - Type Unspecified
FLG71159Medicare UPIN
FLP00138982OtherRAILROAD MEDICARE