Provider Demographics
NPI:1598737033
Name:CHOATE, LAURANCE WALTER (MD)
Entity Type:Individual
Prefix:
First Name:LAURANCE
Middle Name:WALTER
Last Name:CHOATE
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 1:1813 W HARVARD AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2754
Mailing Address - Country:US
Mailing Address - Phone:541-440-6390
Mailing Address - Fax:541-440-6392
Practice Address - Street 1:1813 W HARVARD AVE STE 201
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2754
Practice Address - Country:US
Practice Address - Phone:541-440-6390
Practice Address - Fax:541-440-6392
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36137207Q00000X
ORMD158348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0460477Medicaid
IA39425OtherWELLMARK BC/BS OF IA
IAI15526Medicare ID - Type UnspecifiedPART B
IA0460477Medicaid