Provider Demographics
NPI:1750416210
Name:KERRY A. LAURSEN MD, PA
Entity type:Organization
Organization Name:KERRY A. LAURSEN MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:LAURSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-528-4440
Mailing Address - Street 1:3100 TIMMONS LN
Mailing Address - Street 2:SUITE 565
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-5926
Mailing Address - Country:US
Mailing Address - Phone:713-528-4440
Mailing Address - Fax:713-528-4447
Practice Address - Street 1:3100 TIMMONS LN
Practice Address - Street 2:SUITE 565
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-5926
Practice Address - Country:US
Practice Address - Phone:713-528-4440
Practice Address - Fax:713-528-4447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170771301Medicaid
TX170771301Medicaid
TX00979XMedicare ID - Type Unspecified