Provider Demographics
NPI:1083663967
Name:WAITE, LAWRENCE WESLEY (DO)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:WESLEY
Last Name:WAITE
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 1:2110 EVENSON DR
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8772
Mailing Address - Country:US
Mailing Address - Phone:608-397-6678
Mailing Address - Fax:608-781-5576
Practice Address - Street 1:2110 EVENSON DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8772
Practice Address - Country:US
Practice Address - Phone:608-397-6678
Practice Address - Fax:608-781-5576
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40617204C00000X, 207PE0004X, 207Q00000X
IA03005204C00000X, 207PE0004X, 207Q00000X
IL036-063775204C00000X, 207PE0004X, 207Q00000X
WI37512-04204D00000X
WI37512-021207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE-37161Medicare UPIN