Provider Demographics
NPI:1861516551
Name:EDMISTON, LAURIE (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:EDMISTON
Other - Last Name:WILHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6206 PRESTONSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-2109
Mailing Address - Country:US
Mailing Address - Phone:214-891-0511
Mailing Address - Fax:214-369-5457
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232
Practice Address - Country:US
Practice Address - Phone:972-566-5544
Practice Address - Fax:214-369-5457
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5015207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000L34W4Medicaid
TX00L34WMedicare ID - Type Unspecified
TXP000L34W4Medicaid