1396704151 NPI number — LAWRENCE H PAYTON DC

Table of content: LAWRENCE H PAYTON DC (NPI 1396704151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396704151 NPI number — LAWRENCE H PAYTON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYTON
Provider First Name:
LAWRENCE
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1396704151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4303 S EAST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46227-1514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-781-9636
Provider Business Mailing Address Fax Number:
317-781-9635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4303 S EAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-781-9636
Provider Business Practice Location Address Fax Number:
317-781-9635
Provider Enumeration Date:
03/21/2006

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: 111N00000X , with the licence number:  08001826A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X , with the licence number: 81000010A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000000277442 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200216490B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".