Basic Information
Provider Information | |||||||||
NPI: | 1457306219 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAURIN | ||||||||
FirstName: | JACQUELINE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 418498 | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022418498 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035581544 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3800 RESERVOIR RD NW | ||||||||
Address2: | 2 MAIN | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200072113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024443700 | ||||||||
FaxNumber: | 2024447304 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 07/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | D38858 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RT0003X | MD31154 | DC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Transplant Hepatology |
ID Information
ID | Type | State | Issuer | Description | P00404751 | 01 | DC | RAILROAD MEDICARE | OTHER | 029707900 | 05 | DC |   | MEDICAID | 1000844000 | 05 | WV |   | MEDICAID | 515111200 | 05 | MD |   | MEDICAID | 0000911201 | 05 | DE |   | MEDICAID |