Provider Demographics
NPI:1396275228
Name:DEWALT, LAURA ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELIZABETH
Last Name:DEWALT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:645 PENN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19601-3527
Mailing Address - Country:US
Mailing Address - Phone:610-988-4838
Mailing Address - Fax:610-374-1629
Practice Address - Street 1:1040 LIGGETT AVE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1801
Practice Address - Country:US
Practice Address - Phone:484-220-2955
Practice Address - Fax:610-775-3050
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN61063207Q00000X
PAMT213578390200000X
PAMD478707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program