Provider Demographics
NPI:1972685378
Name:LAURENCE, JODY B (DPM)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:B
Last Name:LAURENCE
Suffix:
Gender:M
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:PO BOX 2033
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-2033
Mailing Address - Country:US
Mailing Address - Phone:916-483-1493
Mailing Address - Fax:888-411-8530
Practice Address - Street 1:5 MEDICAL PLAZA DR STE 110
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2866
Practice Address - Country:US
Practice Address - Phone:916-483-1493
Practice Address - Fax:888-411-8530
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4155213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41550Medicaid
CA000E41550Medicare ID - Type Unspecified
CA000E41550Medicaid