Provider Demographics
NPI:1114035284
Name:BLACK, LAWRENCE RICHARD (DO)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:RICHARD
Last Name:BLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:R
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:13691 METRO PKWY
Practice Address - Street 2:350
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4327
Practice Address - Country:US
Practice Address - Phone:239-768-5313
Practice Address - Fax:239-768-9559
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL055736208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2972830OtherCIGNA
FL007256700Medicaid
FL80628OtherBCBS
FL15649OtherWELLCARE
FL4478694OtherAETNA
FL375522300Medicaid
FLP01192863OtherRAILROAD MCR
FLP304402OtherFREEDOM HEALTH
FL212724OtherAVMED
FL80628OtherBCBS FL
FLP946386OtherOPTIMUM
FL4478694OtherAETNA
FL2972830OtherCIGNA
FL80628YMedicare PIN