Provider Demographics
NPI:1689676967
Name:RICCIARDI, LAURA A (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:RICCIARDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 BERKMAR DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1456
Mailing Address - Country:US
Mailing Address - Phone:434-973-1831
Mailing Address - Fax:434-973-1919
Practice Address - Street 1:3025 BERKMAR DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1456
Practice Address - Country:US
Practice Address - Phone:434-973-1831
Practice Address - Fax:434-973-1919
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101228406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA317302OtherSOUTHERN HEALTH
VA010261864Medicaid
VA181906OtherANTHEM BCBS
VA317302OtherSOUTHERN HEALTH
VA181906OtherANTHEM BCBS