Provider Demographics
NPI:1942596606
Name:MCDERMOTT, LAURA MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:MICHELLE
Last Name:MCDERMOTT
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 1:408 S EAGLE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6079
Mailing Address - Country:US
Mailing Address - Phone:208-545-2131
Mailing Address - Fax:
Practice Address - Street 1:408 S EAGLE RD STE 205
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6079
Practice Address - Country:US
Practice Address - Phone:208-545-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124572208000000X
390200000X
IDM-17071208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program