Provider Demographics
NPI:1538504881
Name:BLACK, LAURA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:BLACK
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 1:707 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21205-1888
Mailing Address - Country:US
Mailing Address - Phone:443-923-9440
Mailing Address - Fax:443-923-9445
Practice Address - Street 1:707 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-1888
Practice Address - Country:US
Practice Address - Phone:443-923-9440
Practice Address - Fax:443-923-9445
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062536208100000X
MDD00951342081P0010X
IN01081976A2081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation