Provider Demographics
NPI:1841376639
Name:DESNICK, LAUREL HELENE (MD)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:HELENE
Last Name:DESNICK
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 1:504 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-3727
Mailing Address - Country:US
Mailing Address - Phone:406-823-6414
Mailing Address - Fax:406-823-6287
Practice Address - Street 1:1001 RIVER DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3716
Practice Address - Country:US
Practice Address - Phone:406-222-0800
Practice Address - Fax:406-222-7606
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036360207R00000X
MT620316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8247553Medicaid
4575OtherINTERNAL ID-MOTOR VEHICLE ID
MT810378200OtherEIN
MTP00420831Medicare Oscar/Certification
WA8247553Medicaid
MT011000496Medicare PIN
AB10887Medicare ID - Type Unspecified
MT0110000458Medicare PIN
4575OtherINTERNAL ID-MOTOR VEHICLE ID