Provider Demographics
NPI:1114925013
Name:WINE, LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:WINE
Suffix:
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 120223
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-0223
Mailing Address - Country:US
Mailing Address - Phone:718-663-9251
Mailing Address - Fax:
Practice Address - Street 1:129 SLOSSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2522
Practice Address - Country:US
Practice Address - Phone:718-226-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159728-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00188256Medicaid
A98833Medicare UPIN
NY00188256Medicaid