Provider Demographics
NPI:1104098110
Name:WITHERS, LAURA TERESA (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:TERESA
Last Name:WITHERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:TERESA
Other - Last Name:GIDEON WITHERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:110 MARGINAL WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2442
Mailing Address - Country:US
Mailing Address - Phone:917-650-5408
Mailing Address - Fax:
Practice Address - Street 1:887 CONGRESS ST STE 210
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3166
Practice Address - Country:US
Practice Address - Phone:207-774-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602330543208600000X, 2086S0127X
FLME1023322086S0102X
ME002800501208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAX172ZMedicare PIN