Provider Demographics
NPI:1932178720
Name:GRANT, LAURA L (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:RICKETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1705 E. BROADWAY, SUITE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5852
Mailing Address - Country:US
Mailing Address - Phone:573-449-9355
Mailing Address - Fax:573-441-9355
Practice Address - Street 1:1705 E. BROADWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6863
Practice Address - Country:US
Practice Address - Phone:573-449-9355
Practice Address - Fax:573-441-9355
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106052207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF88274Medicare UPIN