Provider Demographics
NPI:1104858885
Name:MACTAVISH, LAWRENCE SCOTT II (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:SCOTT
Last Name:MACTAVISH
Suffix:II
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:17215 RED OAK DR
Mailing Address - Street 2:STE 102
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2611
Mailing Address - Country:US
Mailing Address - Phone:281-444-4114
Mailing Address - Fax:281-453-1269
Practice Address - Street 1:17215 RED OAK DR
Practice Address - Street 2:STE 102
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2611
Practice Address - Country:US
Practice Address - Phone:281-444-4114
Practice Address - Fax:281-453-1269
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1715213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172014602Medicaid
TX00448339OtherRR MEDICARE
TX8W6251OtherBCBS
TX80207XOtherBCBS
TXP00397523OtherRR MEDICARE
TX172014603Medicaid
TX00448339OtherRR MEDICARE
TX172014603Medicaid
TX1313110001Medicare NSC
TX8W6251OtherBCBS
TX0660130002Medicare NSC