Provider Demographics
NPI:1023199312
Name:ENNIS, LAWRENCE SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:SCOTT
Last Name:ENNIS
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 1:4485 FURLING LN
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5331
Mailing Address - Country:US
Mailing Address - Phone:850-654-1194
Mailing Address - Fax:850-654-3380
Practice Address - Street 1:4485 FURLING LN
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5331
Practice Address - Country:US
Practice Address - Phone:850-654-1194
Practice Address - Fax:850-654-3380
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG81761Medicare UPIN