Provider Demographics
NPI:1801843230
Name:SMITH, LAURA DIANE (DO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 1ST CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2844
Mailing Address - Country:US
Mailing Address - Phone:636-947-5662
Mailing Address - Fax:636-947-5250
Practice Address - Street 1:300 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2844
Practice Address - Country:US
Practice Address - Phone:636-947-5662
Practice Address - Fax:636-947-5250
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000158417207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200050238Medicare ID - Type UnspecifiedSJHW-MO
MO255050091Medicare ID - Type UnspecifiedSJH-MO