Provider Demographics
NPI:1952367815
Name:KOTH, LAURA L (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:KOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:MELENDRES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1635 DIVISADERO STREET, SUITE 625, BOX 1821
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:415-353-2961
Practice Address - Fax:415-353-2568
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64672207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A6467200Medicaid
CAG56274Medicare UPIN
CA0A6467200Medicaid