Provider Demographics
NPI:1194710392
Name:BERDAHL, LAURIE D (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:D
Last Name:BERDAHL
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 1:2410 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6004
Mailing Address - Country:US
Mailing Address - Phone:970-352-6353
Mailing Address - Fax:970-356-2264
Practice Address - Street 1:2410 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6004
Practice Address - Country:US
Practice Address - Phone:970-352-6353
Practice Address - Fax:970-356-2264
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10381125OtherCAQH
CO840592369006OtherROCKY MTN HEALTH
COBE41887OtherBCBS
CO84059236906OtherPACIFICARE
CO01354125Medicaid
COC98998Medicare PIN
COBE41887OtherBCBS
COCOAAA0026Medicare UPIN