Provider Demographics
NPI:1124001219
Name:LAWRENCE, PETER G (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:G
Last Name:LAWRENCE
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 1446
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38025-1446
Mailing Address - Country:US
Mailing Address - Phone:731-427-9971
Mailing Address - Fax:731-424-2052
Practice Address - Street 1:28 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3947
Practice Address - Country:US
Practice Address - Phone:731-427-9971
Practice Address - Fax:731-424-2052
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000038436208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3892671Medicaid
TN8805391OtherCIGNA
TN4083742OtherBLUE CROSS BLUE SHIELD
TN07646597OtherAETNA
TNP00169177Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TN07646597OtherAETNA
TN8805391OtherCIGNA