Provider Demographics
NPI:1386609345
Name:DODD, LAURIE ROSE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ROSE
Last Name:DODD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 N FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-326-4811
Mailing Address - Fax:520-323-8444
Practice Address - Street 1:2355 N FERGUSON AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-326-4811
Practice Address - Fax:520-323-8444
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23647207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ334087001Medicaid
G21492Medicare UPIN
260086Medicare ID - Type Unspecified