Provider Demographics
NPI:1043315872
Name:DEBOER, LAURENCE WILLIAM VALE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:WILLIAM VALE
Last Name:DEBOER
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 1:430 MEDICAL ARTS CT.
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716
Mailing Address - Country:US
Mailing Address - Phone:307-682-7661
Mailing Address - Fax:307-682-7624
Practice Address - Street 1:430 MEDICAL ARTS CT.
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716
Practice Address - Country:US
Practice Address - Phone:307-682-7661
Practice Address - Fax:307-682-7624
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5853A207RC0000X
TXE0878207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
638OtherMEDICAL LICENSE
WY53D925429OtherCLIA
WY303946OtherBLUE CROSS
WY5853AOtherSTATE LICENSE
WY00783001OtherBLUE CROSS GROUP NUMBER
WY7088727Medicaid
WA8380925Medicaid
WA8380925Medicaid
MT0084575Medicare ID - Type UnspecifiedMEDICAID PROVIDER
638OtherMEDICAL LICENSE
WYW307249Medicare ID - Type UnspecifiedMEDICARE GROUP
WA8380925Medicaid