Provider Demographics
NPI:1043327752
Name:SPACK, LAWRENCE
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:SPACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1547
Mailing Address - Country:US
Mailing Address - Phone:727-456-4250
Mailing Address - Fax:727-346-1044
Practice Address - Street 1:1033 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:SUITE 108
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-1547
Practice Address - Country:US
Practice Address - Phone:727-456-4250
Practice Address - Fax:727-346-1044
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME741052080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253085600Medicaid
FL42298YMedicare PIN