Basic Information
| Provider Information | |||||||||
| NPI: | 1295091007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERSDORF | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ELYSE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1218 EUCLID ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200095330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487091071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 ALTO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059828440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD2015-0076 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12435287 | 05 | NM | MEDICAID |