Provider Demographics
NPI:1659345338
Name:O'HALLORAN, LAURA E (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:E
Last Name:O'HALLORAN
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:3200 TROUP HWY
Practice Address - Street 2:STE 240
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8397
Practice Address - Country:US
Practice Address - Phone:903-510-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL52882086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175071301Medicaid
TXP00315047Medicare PIN
I36156Medicare UPIN
TX8D7706Medicare ID - Type Unspecified