Provider Demographics
NPI:1457413585
Name:CEDERBERG, LAURIE LYNN
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:LYNN
Last Name:CEDERBERG
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 1:1535 RAEGAN WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 DOYLE PARK DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4570
Practice Address - Country:US
Practice Address - Phone:707-526-1800
Practice Address - Fax:707-526-9352
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G672870Medicaid
CAG67287OtherCALIF MED LIS
CA00G672870Medicare ID - Type UnspecifiedMCARE PPIN
CAF14620Medicare UPIN
CAG67287OtherCALIF MED LIS