Provider Demographics
NPI:1679597132
Name:PATRICK, LAURA ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELLEN
Last Name:PATRICK
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 1:2329 TANGLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2015
Mailing Address - Country:US
Mailing Address - Phone:404-785-6549
Mailing Address - Fax:
Practice Address - Street 1:1405 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1060
Practice Address - Country:US
Practice Address - Phone:404-785-6549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0243222085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46188Medicare UPIN