Provider Demographics
NPI:1598751513
Name:PRIDEMORE, LAURA TAYLOR (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:TAYLOR
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:1994 WELLNESS BLVD STE 110
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7768
Practice Address - Country:US
Practice Address - Phone:704-384-8460
Practice Address - Fax:704-384-8465
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2001-01289208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01289Medicaid
NC89130G2Medicaid
SCN01289Medicaid