Provider Demographics
NPI:1295764108
Name:GILMORE, LAURA SHANNON (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SHANNON
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:SHANNON
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1813 ABILENE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2200
Mailing Address - Country:US
Mailing Address - Phone:405-474-7757
Mailing Address - Fax:405-410-9795
Practice Address - Street 1:102 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CARNEGIE
Practice Address - State:OK
Practice Address - Zip Code:73015-9800
Practice Address - Country:US
Practice Address - Phone:800-942-2904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2060322083P0011X
TXN6124208D00000X, 2083P0011X
OK22979208D00000X, 207W00000X, 2083P0011X
ARE72622083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200086480BMedicaid
OK22979OtherOK LICENSE #
OK34574OtherOBNDD
TXP0172984OtherTX DPS
ARE7262OtherMEDICAL LICENSE
OK22979OtherOK LICENSE #
TXP0172984OtherTX DPS