Provider Demographics
NPI:1518180785
Name:MENDYK, LAURA L (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:MENDYK
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 1:753 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1003
Mailing Address - Country:US
Mailing Address - Phone:608-835-2222
Mailing Address - Fax:608-835-1090
Practice Address - Street 1:753 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1003
Practice Address - Country:US
Practice Address - Phone:608-835-2222
Practice Address - Fax:608-835-1090
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52963-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1518180785Medicaid
WIK400157388Medicare PIN
WI741501793Medicare PIN
WIP00914196Medicare PIN