Provider Demographics
NPI:1922055805
Name:DEMOPOULOS, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DEMOPOULOS
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 1:419 COZY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PRATTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12468-7017
Mailing Address - Country:US
Mailing Address - Phone:215-429-4035
Mailing Address - Fax:
Practice Address - Street 1:419 COZY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PRATTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12468-7017
Practice Address - Country:US
Practice Address - Phone:215-429-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060528L207R00000X
NY173002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016479710003Medicaid
PA959094Medicare ID - Type Unspecified
PA0016479710003Medicaid