Provider Demographics
NPI:1164417358
Name:WEIDER, LAURENCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:A
Last Name:WEIDER
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 1:7777 FOREST LN
Mailing Address - Street 2:SUITE B-145
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2505
Mailing Address - Country:US
Mailing Address - Phone:972-566-8444
Mailing Address - Fax:972-566-8453
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:SUITE B-145
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-8444
Practice Address - Fax:972-566-8453
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ46022082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181391100OtherOWCP
TX76467OtherAMERIGROUP
TX030446101Medicaid
TX50EJOtherBLUE CROSS BLUE SHIELD
TXG97499Medicare UPIN
TX030446101Medicaid