1407849839 NPI number — JAMES X LAWRENCE OD

Table of content: JAMES X LAWRENCE OD (NPI 1407849839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407849839 NPI number — JAMES X LAWRENCE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWRENCE
Provider First Name:
JAMES
Provider Middle Name:
X
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407849839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 N TAMIAMI TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSKIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33570-3769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-645-3831
Provider Business Mailing Address Fax Number:
813-645-4402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 N TAMIAMI TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSKIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33570-3769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-645-3831
Provider Business Practice Location Address Fax Number:
813-645-4402
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC001668 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 078359500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2200636 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4317979 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9600540 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 19445A . This is a "BCBS FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 078359500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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