Provider Demographics
NPI:1619944022
Name:LAURIE, MICHAEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:LAURIE
Suffix:
Gender:M
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:PO BOX 24410
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4010 AERIAL WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-9757
Practice Address - Country:US
Practice Address - Phone:541-687-6349
Practice Address - Fax:541-242-8361
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19654207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR077907Medicaid
ORRR PTAN 110118406Medicare PIN
OR077907Medicaid
ORR011WFBFRYMedicare PIN