1104896794 NPI number — DR. BRIAN DOUGLAS LAWENDA M.D.

Table of content: DR. BRIAN DOUGLAS LAWENDA M.D. (NPI 1104896794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104896794 NPI number — DR. BRIAN DOUGLAS LAWENDA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWENDA
Provider First Name:
BRIAN
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1104896794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3080 HARBOR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-6720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-883-2199
Provider Business Mailing Address Fax Number:
941-979-5041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8026 S TAMIAMI TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-220-6460
Provider Business Practice Location Address Fax Number:
941-220-5284
Provider Enumeration Date:
01/25/2006

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: 2085R0001X , with the licence number:  A87177 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 13433 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: MD60622589 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: ME167833 , 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: 4738395 . This is a "CIGNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1104896794 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457283 . This is a "GHI" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 01371595 . This is a "AMERIGROUP" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 122055900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7839863 . This is a "AETNA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: P01650856 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7839863 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00894440 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1104896794 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500708662 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 518641 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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