Provider Demographics
NPI:1003886649
Name:KNOLL, LAURENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:KNOLL
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 1:385 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516
Mailing Address - Country:US
Mailing Address - Phone:203-932-8080
Mailing Address - Fax:203-932-8388
Practice Address - Street 1:385 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-932-8080
Practice Address - Fax:203-932-8388
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400016904OtherMEDICARE PTAN
B84574Medicare UPIN