Provider Demographics
NPI:1609846237
Name:LAUR, MIKE C (DPM)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:C
Last Name:LAUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2667 E GALA CT STE 130
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2788
Mailing Address - Country:US
Mailing Address - Phone:208-795-5090
Mailing Address - Fax:208-459-8628
Practice Address - Street 1:2667 E GALA CT STE 130
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2788
Practice Address - Country:US
Practice Address - Phone:208-855-5955
Practice Address - Fax:208-459-8628
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000883213E00000X
IDP-274213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000855434AMedicaid
ID00855434BMedicaid
GA00855434CMedicaid
GA2701696OtherEVERCARE
GA332893Medicaid
GA10051376Medicaid
GA2308614OtherAETNA
GA2600040OtherUNITED HEALTHCARE
GA00855434CMedicaid
GA000855434AMedicaid
GA2600040OtherUNITED HEALTHCARE