Provider Demographics
NPI:1639312168
Name:VAN DONSELAAR, LAURIE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:MARIE
Last Name:VAN DONSELAAR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:MARIE
Other - Last Name:KRUSKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 SOUTHFIELD DR STE 1370
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4300
Mailing Address - Country:US
Mailing Address - Phone:317-837-5566
Mailing Address - Fax:317-837-5580
Practice Address - Street 1:6911 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8926
Practice Address - Country:US
Practice Address - Phone:317-272-8033
Practice Address - Fax:317-272-8044
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004178A207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201096470Medicaid
IN940550043Medicare PIN