Provider Demographics
NPI:1487799490
Name:COUNCILL, LAURAJEAN (DPM)
Entity type:Individual
Prefix:
First Name:LAURAJEAN
Middle Name:
Last Name:COUNCILL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 MOUNTAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2015
Mailing Address - Country:US
Mailing Address - Phone:410-437-9366
Mailing Address - Fax:410-437-8107
Practice Address - Street 1:3021 MOUNTAIN RD STE A
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-2015
Practice Address - Country:US
Practice Address - Phone:410-437-9366
Practice Address - Fax:410-437-8107
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08828183500000X
MD00971213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKBQ4COOtherBLUE CROSS BLUE SHIELD
DCW219-0001OtherBLUE CROSS BLUE SHIELD
DCW219-0001OtherBLUE SHIELD FEP
MD43428-8700Medicaid
MDKBQ4COOtherBLUE CROSS BLUE SHIELD