Provider Demographics
NPI:1245284314
Name:ARCHULETA, LAURA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ARCHULETA
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 997
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-0997
Mailing Address - Country:US
Mailing Address - Phone:701-667-4600
Mailing Address - Fax:701-530-3780
Practice Address - Street 1:2500 SUNSET DRIVE NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554
Practice Address - Country:US
Practice Address - Phone:701-667-4600
Practice Address - Fax:701-530-3780
Is Sole Proprietor?:No
Enumeration Date:2006-05-21
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9721207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454485Medicaid
ND1454485Medicaid
NDH75006Medicare UPIN
ND13137Medicaid
ND881S4AROtherMNBS #
ND881S2AROtherMNBS #
ND0118483OtherMEDICA #
ND881S3AROtherMNBS #
NDH75006Medicare UPIN
ND24666Medicare ID - Type UnspecifiedND MEDICARE #
ND0118484OtherMEDICA #
ND881S1AROtherMNBS #
ND24665Medicare ID - Type UnspecifiedND MEDICARE #
NDN712995Medicare PIN
NDP00457009OtherRR MEDICARE
ND2175450OtherAMERICA'S PPO/ARAZ #
ND256931100Medicaid
ND34897OtherLHS/BANNER HEALTH #
ND0118486OtherMEDICA #
NDDA9061042060OtherPREFERRED ONE #
ND24665OtherNDBS #