Provider Demographics
NPI:1639243231
Name:GIVANT, LAURA G (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:GIVANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:GRACE
Other - Last Name:GIVANT-EASTLICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3466
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:2025 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2115
Practice Address - Country:US
Practice Address - Phone:916-973-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61804208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A618040Medicaid
00A618040Medicare ID - Type Unspecified
G88382Medicare UPIN