Provider Demographics
NPI:1194781344
Name:CHAMPAGNE, LAURA R (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:RISHMANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6423
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:685 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5665
Practice Address - Country:US
Practice Address - Phone:480-821-2838
Practice Address - Fax:480-821-9444
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32254208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ847121Medicaid
AZZ190467Medicare PIN
AZI06498Medicare UPIN
AZ170732Medicare PIN