Provider Demographics
NPI:1558323881
Name:MARK, LAURA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:J
Last Name:MARK
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 1:414 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:VA
Mailing Address - Zip Code:22572-4291
Mailing Address - Country:US
Mailing Address - Phone:804-693-5068
Mailing Address - Fax:804-693-7407
Practice Address - Street 1:414 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:VA
Practice Address - Zip Code:22572-4291
Practice Address - Country:US
Practice Address - Phone:804-333-3671
Practice Address - Fax:804-333-3657
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010530932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAO83589OtherSOUTHERN HEALTH
VA140026OtherANTHEM
VA140026OtherHEALTHKEEPERS
VAO83589Medicaid
VA140027OtherHEALTHKEEPERS
VA15-13209OtherUNITED BEHAVIORAL HEALTH
VA2004239OtherCIGNA
VA331733OtherTRICARE
VA140027Medicaid
VA406380OtherVALUE OPTIONS
VA7303231OtherAETNA
VA140026Medicaid
VA140027OtherANTHEM
VA2004239OtherCIGNA