Provider Demographics
NPI:1265436505
Name:DIAMANDOPOULOS, LAURA A (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:DIAMANDOPOULOS
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 48089
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8089
Mailing Address - Country:US
Mailing Address - Phone:706-389-3740
Mailing Address - Fax:
Practice Address - Street 1:2470 DANIELLS BRIDGE RD STE 251
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6192
Practice Address - Country:US
Practice Address - Phone:706-389-3440
Practice Address - Fax:706-353-2205
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA49003207RC0000X
NM2001-0326207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN054663100Medicaid
NM5913707Medicaid
NM5913707Medicaid
MNG86137Medicare UPIN
NMG86137Medicare UPIN
NM341421705Medicare PIN