Provider Demographics
NPI:1053713271
Name:LAUREL, MIA (DO)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:LAUREL
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 1:147 BEACH RD STE A
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-1733
Mailing Address - Country:US
Mailing Address - Phone:631-288-7746
Mailing Address - Fax:631-288-7111
Practice Address - Street 1:147 BEACH RD STE A
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-1733
Practice Address - Country:US
Practice Address - Phone:631-288-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty