Provider Demographics
NPI:1861537532
Name:BOTHWELL, LAURIE (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:BOTHWELL
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 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 BATA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017
Practice Address - Country:US
Practice Address - Phone:410-575-6611
Practice Address - Fax:410-273-7509
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57084207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine