Provider Demographics
NPI:1548260912
Name:PRATT, LAURA KELLAM (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KELLAM
Last Name:PRATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LEE
Other - Last Name:KELLAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:301 CONCOURSE BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5643
Mailing Address - Country:US
Mailing Address - Phone:804-549-4030
Mailing Address - Fax:804-549-4032
Practice Address - Street 1:280 CHARLES DIMMOCK PKWY
Practice Address - Street 2:SUITE 4
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2940
Practice Address - Country:US
Practice Address - Phone:804-526-7364
Practice Address - Fax:804-526-7394
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231692207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00047267OtherRAILROAD MEDICARE
7442479OtherAETNA
VA010008280Medicaid
0300585OtherUNITED HEALTHCARE
230056OtherSOUTHERN HEALTH
465745OtherANTHEM
465745OtherANTHEM
7442479OtherAETNA