Provider Demographics
NPI:1336185321
Name:HUMPHREY, LAUREL L (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:L
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAUREL
Other - Middle Name:LEE
Other - Last Name:HUMPHREY POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:TWO ST. MARK'S PLACE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-1259
Mailing Address - Country:US
Mailing Address - Phone:979-242-5605
Mailing Address - Fax:979-242-5619
Practice Address - Street 1:TWO ST. MARK'S PLACE
Practice Address - Street 2:SUITE 130
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1259
Practice Address - Country:US
Practice Address - Phone:979-242-5605
Practice Address - Fax:979-242-5619
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1773208600000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184272601Medicaid
TX184272601Medicaid
TX612049Medicare PIN