Provider Demographics
NPI:1356564447
Name:BOTH, LAURA A (MD)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:A
Last Name:BOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:FOUDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1144 W PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1842
Mailing Address - Country:US
Mailing Address - Phone:574-546-5363
Mailing Address - Fax:574-546-2575
Practice Address - Street 1:1144 W. PLYMOUTH ST.
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506
Practice Address - Country:US
Practice Address - Phone:574-546-5363
Practice Address - Fax:574-546-2575
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068122A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine