Provider Demographics
NPI:1720064777
Name:PRESTON, LAURA LARAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LARAINE
Last Name:PRESTON
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 1:3217 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4413
Mailing Address - Country:US
Mailing Address - Phone:850-942-5728
Mailing Address - Fax:850-671-4415
Practice Address - Street 1:3217 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4413
Practice Address - Country:US
Practice Address - Phone:850-942-5728
Practice Address - Fax:850-671-4415
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048338900Medicaid
FL07051OtherBLUE CROSS BLUE SHIELD
FL1174719777OtherGROUP NPI FOR MCR
FL050184OtherVISTA
FL1174719777OtherGROUP NPI FOR MCR
FL050184OtherVISTA