Provider Demographics
NPI:1770590523
Name:MONCKTON, LAURANCE
Entity type:Individual
Prefix:
First Name:LAURANCE
Middle Name:
Last Name:MONCKTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:618-462-3191
Mailing Address - Fax:618-462-3379
Practice Address - Street 1:4 MEMORIAL DR
Practice Address - Street 2:STE 230
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-462-3191
Practice Address - Fax:618-462-3379
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074993208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360749932Medicaid
C48907Medicare UPIN
IL0360749932Medicaid