Provider Demographics
NPI:1053393553
Name:HAMILTON, LAURIE LINN (DO)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:LINN
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 N LANSING AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-5907
Mailing Address - Country:US
Mailing Address - Phone:918-587-2171
Mailing Address - Fax:
Practice Address - Street 1:1334 N LANSING AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-5907
Practice Address - Country:US
Practice Address - Phone:918-587-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25177207V00000X
CA20A8886207V00000X
OK3891207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00412787OtherTRAV RR PTAN NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OK100211740AMedicaid
OR1407812365OtherMEDICARE GROUP NPI NUMBER
OK371803OtherGROUP MEDICARE PTAN
ORCB3544OtherTRAV RR GROUP NUMBER
OK731177858OtherGROUP TAX ID NUMBER
OR0577260001Medicare NSC
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER