Provider Demographics
NPI:1174719777
Name:LAURA PRESTON MD PA
Entity type:Organization
Organization Name:LAURA PRESTON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-942-5728
Mailing Address - Street 1:3217 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4413
Mailing Address - Country:US
Mailing Address - Phone:850-942-5728
Mailing Address - Fax:850-671-4415
Practice Address - Street 1:3217 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4413
Practice Address - Country:US
Practice Address - Phone:850-942-5728
Practice Address - Fax:850-671-4415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53543173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048338900Medicaid
FL048338900Medicaid
FLK4989Medicare PIN