Provider Demographics
NPI:1184749319
Name:BAUMSTARK, LAUREL L (MD)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:L
Last Name:BAUMSTARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:L
Other - Last Name:WALTER-BAUMSTARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:211 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041-1047
Mailing Address - Country:US
Mailing Address - Phone:573-330-3007
Mailing Address - Fax:
Practice Address - Street 1:211 W 2ND ST
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1047
Practice Address - Country:US
Practice Address - Phone:573-330-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO95757207Q00000X
MOMD100863207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00473866OtherRAILROAD MEDICARE
MO208075036Medicaid
950802943Medicare PIN
P00473866OtherRAILROAD MEDICARE