Provider Demographics
NPI:1831289206
Name:BLAKEMORE, LAUREL CLAIRE (MD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:CLAIRE
Last Name:BLAKEMORE
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 1:3023 HAMAKER CT STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2240
Mailing Address - Country:US
Mailing Address - Phone:703-848-6627
Mailing Address - Fax:
Practice Address - Street 1:3023 HAMAKER CT STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2240
Practice Address - Country:US
Practice Address - Phone:703-848-6627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117758207X00000X
DCMD034954207XP3100X
VA0101236348207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009880000Medicaid
F78374Medicare UPIN
FLHP575ZMedicare PIN