Provider Demographics
NPI:1316141492
Name:KONCZAL, LAURA LEE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LEE
Last Name:KONCZAL
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 1:11100 EUCLID AVE
Mailing Address - Street 2:LAKESIDE STE 1500
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106
Mailing Address - Country:US
Mailing Address - Phone:216-844-3936
Mailing Address - Fax:216-844-7497
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085739207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH465081OtherWELLCARE
OH755709OtherBUCKEYE
OH2839138Medicaid
PA1022542000001Medicaid
OH465081OtherWELLCARE