Provider Demographics
NPI:1174508055
Name:LORENZEN, EARL A (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:A
Last Name:LORENZEN
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 709
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-0709
Mailing Address - Country:US
Mailing Address - Phone:229-567-3361
Mailing Address - Fax:
Practice Address - Street 1:354 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:GA
Practice Address - Zip Code:31714-5222
Practice Address - Country:US
Practice Address - Phone:229-567-3361
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG01859Medicare UPIN
GA08BBQQJMedicare ID - Type Unspecified