=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306895800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA URETA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 03/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3345 SOUTHWESTERN BLVD
-----------------------------------------------------
City | ORCHARD PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14127-1506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-656-4899
-----------------------------------------------------
Fax | 716-250-5929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6255 SHERIDAN DR SUITE 304
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-4836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-857-8666
-----------------------------------------------------
Fax | 716-857-8944
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 133187-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------