Healthcare Provider Details

I. General information

NPI: 1437107919
Provider Name (Legal Business Name): LAURA N WEIDT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 KEENE ST
COLUMBIA MO
65201-6625
US

IV. Provider business mailing address

401 KEENE ST
COLUMBIA MO
65201-6625
US

V. Phone/Fax

Practice location:
  • Phone: 573-876-1620
  • Fax: 573-876-1663
Mailing address:
  • Phone: 573-876-1620
  • Fax: 573-876-1663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number2005012205
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: