MEDICARE: LAURIE BOQUET DORY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	J4779	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3378225	OTHER	TX	BCBS BLUE LINK NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0076EQ	OTHER	TX	BCBS NUMBER
4	7540001	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1417930900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE BOQUET DORY M.D.

Provider Business Mailing Address
First Line	:	901 TRAVIS AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3137
Country	:	US
Telephone Number	:	817-332-5585
Fax Number	:	817-332-5377

Provider Business Practice Location Address
First Line	:	901 TRAVIS AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3137
Country	:	US
Telephone Number	:	817-332-5585
Fax Number	:	817-332-5377

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	07/28/2008

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