Basic Information
Provider Information | |||||||||
NPI: | 1750602199 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARSH | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PERSKY | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8441 STATE HWY 47 | ||||||||
Address2: | STE 3115 | ||||||||
City: | BRYAN | ||||||||
State: | TX | ||||||||
PostalCode: | 77807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9794369703 | ||||||||
FaxNumber: | 9794360072 | ||||||||
Practice Location | |||||||||
Address1: | 2900 E 29TH ST | ||||||||
Address2: |   | ||||||||
City: | BRYAN | ||||||||
State: | TX | ||||||||
PostalCode: | 778022622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9797768440 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2010 | ||||||||
LastUpdateDate: | 10/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | P5288 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | P5288 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2J4539 | 01 | TX | MEDICARE PTAN | OTHER | 335151202 | 05 | TX |   | MEDICAID |