Provider Demographics
NPI:1962908731
Name:BOU-MAROUN, LAURA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOU-MAROUN
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 1:5340 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2006
Mailing Address - Country:US
Mailing Address - Phone:347-401-5557
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:734-740-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN779892080P0207X
MI43015039992080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Single Specialty