Provider Demographics
NPI:1295091007
Name:WALTERSDORF, LAUREN ELYSE
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ELYSE
Last Name:WALTERSDORF
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 1:1218 EUCLID ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-5330
Mailing Address - Country:US
Mailing Address - Phone:248-709-1071
Mailing Address - Fax:
Practice Address - Street 1:1035 ALTO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2406
Practice Address - Country:US
Practice Address - Phone:505-982-4425
Practice Address - Fax:505-982-8440
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0076207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12435287Medicaid