Provider Demographics
NPI:1174596860
Name:ESSWEIN, LAURA A (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:ESSWEIN
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 1:10024 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1829
Mailing Address - Country:US
Mailing Address - Phone:314-919-2555
Mailing Address - Fax:314-919-2577
Practice Address - Street 1:10024 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1829
Practice Address - Country:US
Practice Address - Phone:314-919-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109792207KA0200X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174596860Medicaid
MOP01280989OtherRAILROAD MEDICARE
MO967225280Medicare PIN
MOG39451Medicare UPIN