Healthcare Provider Details

I. General information

NPI: 1275273195
Provider Name (Legal Business Name): LAURA HALLOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA MANN MD

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11525 HAYNES BRIDGE RD STE 200
ALPHARETTA GA
30009-4822
US

IV. Provider business mailing address

11525 HAYNES BRIDGE RD STE 200
ALPHARETTA GA
30009-4822
US

V. Phone/Fax

Practice location:
  • Phone: 770-751-0800
  • Fax: 770-751-7198
Mailing address:
  • Phone: 770-751-7198
  • Fax: 770-751-0800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number104266
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL87955
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: