Basic Information
Provider Information | |||||||||
NPI: | 1326456674 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOFER | ||||||||
FirstName: | LAUREL | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRABAWITZ | ||||||||
OtherFirstName: | LAUREL | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD, | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3700N LAKE SHORE DR 124 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606134200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149075158 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5850 CORAL RIDGE DR STE 106 | ||||||||
Address2: |   | ||||||||
City: | CORAL SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 330763379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9547148200 | ||||||||
FaxNumber: | 9548402626 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2014 | ||||||||
LastUpdateDate: | 07/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME143182 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.