Provider Demographics
NPI:1124000633
Name:VIERO-DOTHAGE, LAURA MARIE (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:VIERO-DOTHAGE
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:PO BOX 4853
Mailing Address - Street 2:DEPT 4036
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-4853
Mailing Address - Country:US
Mailing Address - Phone:630-734-0200
Mailing Address - Fax:630-734-1560
Practice Address - Street 1:12303 DEPAUL DR
Practice Address - Street 2:DEPAUL HEALTH CENTER
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-344-6000
Practice Address - Fax:630-734-1560
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001493207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I19460Medicare UPIN