Healthcare Provider Details

I. General information

NPI: 1114903945
Provider Name (Legal Business Name): JOHN M LAURENT OD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 UNIVERSITY BOULEVARD HPB G080A
BIRMINGHAM AL
35294-0010
US

IV. Provider business mailing address

1716 UNIVERSITY BOULEVARD HPB G080A
BIRMINGHAM AL
35294-0010
US

V. Phone/Fax

Practice location:
  • Phone: 205-975-2020
  • Fax: 205-934-6755
Mailing address:
  • Phone: 205-975-2020
  • Fax: 205-934-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberR-175-TA-794
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: