Healthcare Provider Details

I. General information

NPI: 1366412538
Provider Name (Legal Business Name): LAURIE BUMGARNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 RANDOLPH RD SUITE 175
CHARLOTTE NC
28207-1100
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-1050
  • Fax: 704-316-1051
Mailing address:
  • Phone: 704-316-1050
  • Fax: 704-316-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38018
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: