Healthcare Provider Details

I. General information

NPI: 1295091007
Provider Name (Legal Business Name): DR. LAUREN ELYSE WALTERSDORF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ALTO ST
SANTA FE NM
87501-2406
US

IV. Provider business mailing address

1218 EUCLID ST NW
WASHINGTON DC
20009-5330
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4425
  • Fax: 505-982-8440
Mailing address:
  • Phone: 248-709-1071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2015-0076
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: