Provider Demographics
NPI:1063496594
Name:SHOEMAKER, LAWRENCE RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:RAYMOND
Last Name:SHOEMAKER
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 1:725 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-6340
Mailing Address - Fax:315-464-6329
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-6340
Practice Address - Fax:315-464-6329
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2643732080P0210X
KY35271208000000X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012296800Medicaid
KY64252711Medicaid
NY03427103Medicaid
IN200111660Medicaid
KY64252711Medicaid
NYJ400065898Medicare PIN
FLHW298ZMedicare PIN
KY777002Medicare PIN