Provider Demographics
NPI:1912437617
Name:BRANCH, LAUREL LACKEY (MD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:LACKEY
Last Name:BRANCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:SHELBY
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR DEPT 956
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0956
Practice Address - Country:US
Practice Address - Phone:858-657-5278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51154207R00000X
CAA172755207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine