Basic Information
| Provider Information | |||||||||
| NPI: | 1346358579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKSTON | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OHNESORGE | ||||||||
| OtherFirstName: | LAURIE | ||||||||
| OtherMiddleName: | A. | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695712 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 816 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WILLOW SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657931518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172692490 | ||||||||
| FaxNumber: | 4172692492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2000154878 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204998405 | 05 | MO | MEDICAID | 128140 | 01 | BLUE CROSS MO | OTHER |