Provider Demographics
NPI:1962454017
Name:LEBEAU, LAURA M (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:M
Last Name:LEBEAU
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 S AUSTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2012
Mailing Address - Country:US
Mailing Address - Phone:708-863-5376
Mailing Address - Fax:708-863-5375
Practice Address - Street 1:2124 S AUSTIN BLVD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2012
Practice Address - Country:US
Practice Address - Phone:708-863-5376
Practice Address - Fax:708-863-5375
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004478213E00000X
WI835025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004478Medicaid
60000161OtherBLUE CROSS BLUE SHIELD
0732240001OtherDEMERC # WITH PPG
ILL87062Medicare ID - Type UnspecifiedPPG GROUP # 753600
WIP00953286Medicare PIN
IL480033009Medicare PIN
WI864760021Medicare PIN
60000161OtherBLUE CROSS BLUE SHIELD
ILK50161Medicare PIN
0732240001OtherDEMERC # WITH PPG
WI865500020Medicare PIN
WIP00953286Medicare PIN
959430Medicare ID - Type Unspecified
WI814350020Medicare PIN
WI864920023Medicare PIN
ILU25239Medicare UPIN
ILL87059Medicare ID - Type UnspecifiedPPG GROUP # 560750
WI850700018Medicare PIN
WI864760021Medicare PIN
ILL87062Medicare ID - Type UnspecifiedPPG GROUP # 753600