1043315872 NPI number — DR. LAURENCE WILLIAM VALE DEBOER M.D.

Table of content: DR. LAURENCE WILLIAM VALE DEBOER M.D. (NPI 1043315872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043315872 NPI number — DR. LAURENCE WILLIAM VALE DEBOER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEBOER
Provider First Name:
LAURENCE
Provider Middle Name:
WILLIAM VALE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043315872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 MEDICAL ARTS CT.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILLETTE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-682-7661
Provider Business Mailing Address Fax Number:
307-682-7624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 MEDICAL ARTS CT.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILLETTE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-682-7661
Provider Business Practice Location Address Fax Number:
307-682-7624
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  5853A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X , with the licence number: E0878 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 638 . This is a "MEDICAL LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 53D925429 . This is a "CLIA" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 303946 . This is a "BLUE CROSS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 5853A . This is a "STATE LICENSE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 00783001 . This is a "BLUE CROSS GROUP NUMBER" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 7088727 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8380925 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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