Provider Demographics
NPI:1013182591
Name:TARASUK, LAWRENCE J (DO)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:TARASUK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2340
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11969-2340
Mailing Address - Country:US
Mailing Address - Phone:631-283-2100
Mailing Address - Fax:631-283-5731
Practice Address - Street 1:325 MEETING HOUSE LN
Practice Address - Street 2:BLDG 2 SUITE 403
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5087
Practice Address - Country:US
Practice Address - Phone:631-283-2100
Practice Address - Fax:631-283-5731
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2009-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248412208600000X
NY248415208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY248412OtherLICENSE
NY02978994Medicaid