Provider Demographics
NPI:1649416199
Name:WU, LAURA JUICHEN (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JUICHEN
Last Name:WU
Suffix:
Gender:F
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:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:SUITE 850
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1951
Practice Address - Country:US
Practice Address - Phone:903-535-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP200331362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX310184YK62Medicare PIN