Healthcare Provider Details

I. General information

NPI: 1972685378
Provider Name (Legal Business Name): JODY B LAURENCE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MEDICAL PLAZA DR STE 110
ROSEVILLE CA
95661-2866
US

IV. Provider business mailing address

PO BOX 2033
FOLSOM CA
95763-2033
US

V. Phone/Fax

Practice location:
  • Phone: 916-483-1493
  • Fax: 888-411-8530
Mailing address:
  • Phone: 916-483-1493
  • Fax: 888-411-8530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE4155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: