Provider Demographics
NPI:1912133257
Name:SHEA, LAURA R (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:SHEA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10065 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6389
Mailing Address - Country:US
Mailing Address - Phone:352-596-4660
Mailing Address - Fax:352-596-4674
Practice Address - Street 1:10065 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:WEEKI WACHEE
Practice Address - State:FL
Practice Address - Zip Code:34613-6389
Practice Address - Country:US
Practice Address - Phone:352-596-4660
Practice Address - Fax:352-596-4674
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS014711207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RU82UOtherBCBS
FL104091700Medicaid