Provider Demographics
NPI:1366402216
Name:O'MALLEY, LAURA K (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:O'MALLEY
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 1:3333 E CAMELBACK RD STE 122
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2323
Mailing Address - Country:US
Mailing Address - Phone:602-522-1900
Mailing Address - Fax:602-381-3281
Practice Address - Street 1:3333 E CAMELBACK RD STE 122
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2323
Practice Address - Country:US
Practice Address - Phone:602-522-1900
Practice Address - Fax:602-381-3281
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ363028Medicaid
F61253Medicare UPIN
76249Medicare ID - Type Unspecified