Provider Demographics
NPI:1073723987
Name:CHILDRESS, LORENZO III (MD)
Entity Type:Individual
Prefix:DR
First Name:LORENZO
Middle Name:
Last Name:CHILDRESS
Suffix:III
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:2855 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2807
Practice Address - Country:US
Practice Address - Phone:240-427-1926
Practice Address - Fax:240-427-1927
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC340279YWV2Medicare PIN
MD208839YVZMedicare PIN
MD208839ZDDBMedicare PIN