Provider Demographics
NPI:1700875507
Name:BEVILACQUA, LAURA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9135
Mailing Address - Street 2:ATT:SHARON SILVA
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-9135
Mailing Address - Country:US
Mailing Address - Phone:603-890-4404
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA155889208000000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30201468Medicaid
MA75-00451OtherUNITED HEALTHCARE MA
CT003136000Medicaid
NY2357326Medicaid
MAJ21189OtherBCBS MA
MA3198235Medicaid
RILB45398Medicaid
NJ8753709Medicaid
MA99487301OtherNETWORK HEALTH
MAJ21189OtherHMO BLUE
MAAA9205OtherHARVARD PILGRIM
MAJ21189OtherBCBS MA
MA3198235Medicaid