Basic Information
| Provider Information | |||||||||
| NPI: | 1386685642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIMBACK-GRAHAM | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10744 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337578744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664928 | ||||||||
| Practice Location | |||||||||
| Address1: | 10330 N DALE MABRY HWY STE 190 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336184404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139637788 | ||||||||
| FaxNumber: | 8134438149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME112872 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000500480005 | 01 | BC/BS | OTHER | 1211500 | 01 | IHA | OTHER | 000500480004 | 01 | BC/BS | OTHER | 0065758-00 | 05 | FL | MEDICAID | 08047000068 | 01 | FIDELIS | OTHER | 040426002037 | 01 | FIDELIS | OTHER | 0019433420001 | 05 | PA | MEDICAID | 00850591 | 05 | NY | MEDICAID | 00010074902 | 01 | UNIVERA | OTHER |