Provider Demographics
NPI:1578182911
Name:REZAC, LAURA MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:REZAC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DISTRICT BLVD APT 536
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6477
Mailing Address - Country:US
Mailing Address - Phone:605-254-3418
Mailing Address - Fax:
Practice Address - Street 1:2720 FAIRVIEW AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1306
Practice Address - Country:US
Practice Address - Phone:651-634-1410
Practice Address - Fax:651-689-8340
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79542207ND0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program