Provider Demographics
NPI:1790348472
Name:ARCHIBALD, LAURA KOOISTRA (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:KOOISTRA
Last Name:ARCHIBALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:JOY
Other - Last Name:KOOISTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:415 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5003
Practice Address - Country:US
Practice Address - Phone:812-333-7433
Practice Address - Fax:812-333-7435
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01092483A207ND0101X, 207N00000X, 207ND0101X
MN73044207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery