Provider Demographics
NPI:1720190309
Name:BROYLES, LAURA NICHOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:NICHOLE
Last Name:BROYLES
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 1:750 SHERWOOD RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5229
Mailing Address - Country:US
Mailing Address - Phone:404-875-3678
Mailing Address - Fax:404-875-3678
Practice Address - Street 1:341 PONCE DE LEON AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2012
Practice Address - Country:US
Practice Address - Phone:404-616-6304
Practice Address - Fax:404-616-9732
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053839207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20072A001Medicare UPIN