Provider Demographics
NPI:1265523823
Name:SHIPMAN, LAURA JEAN
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:SHIPMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 NATHAN DEAN BYP
Mailing Address - Street 2:
Mailing Address - City:ROCKMART
Mailing Address - State:GA
Mailing Address - Zip Code:30153-2019
Mailing Address - Country:US
Mailing Address - Phone:678-685-5003
Mailing Address - Fax:770-684-7693
Practice Address - Street 1:5220 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2739
Practice Address - Country:US
Practice Address - Phone:770-439-1426
Practice Address - Fax:770-943-2550
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002903152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019641200001Medicaid
PA1019641200001Medicaid
PAU17849Medicare UPIN