Provider Demographics
NPI:1093708661
Name:LAWRENCE, SUSAN DONNA (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DONNA
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:141 COLUMBUS ROAD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1315
Mailing Address - Country:US
Mailing Address - Phone:740-592-4229
Mailing Address - Fax:740-592-4232
Practice Address - Street 1:141 COLUMBUS ROAD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1315
Practice Address - Country:US
Practice Address - Phone:740-592-4229
Practice Address - Fax:740-592-4232
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005458L207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0919153Medicaid
311155352OtherBUREAU OF MENTALLY HANDIC
OHLA2024975Medicare PIN
OH0919153Medicaid
311155352OtherAETNA
311155352OtherPPO NEXT
F59986Medicare UPIN
OHLA2024975Medicare PIN
311155352OtherEV BENEFITS
311155352OtherBUREAU OF MENTALLY HANDIC
OH0919153Medicaid
1204538OtherUNITED HEALTHCARE
311155352OtherCENTRAL BENEFITS
OH311155352OtherMEDIGOLD-CHILLICOTHE OFFI
311155352OtherTRICARE
311155352OtherGREAT WEST
OH000000297508OtherANTHEM