Provider Demographics
NPI:1245442086
Name:FEDOR, LAUREL A (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:A
Last Name:FEDOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:A
Other - Last Name:HENSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-7950
Mailing Address - Fax:801-387-7955
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3195
Practice Address - Country:US
Practice Address - Phone:801-387-3382
Practice Address - Fax:801-387-3259
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14794207R00000X
UT7812473-1205207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00988893OtherMEDICARE RAILROAD
UTU000074929Medicare PIN