Provider Demographics
NPI:1174508774
Name:MINARDI, LAWRENCE MATTHEW
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:MATTHEW
Last Name:MINARDI
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:LAWRENCE
Other - Middle Name:MATTHEW
Other - Last Name:MINARDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:500 DONNALLY ST
Mailing Address - Street 2:STE 1
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1600
Mailing Address - Country:US
Mailing Address - Phone:304-343-0331
Mailing Address - Fax:
Practice Address - Street 1:500 DONNALLY ST
Practice Address - Street 2:BLDG B NORTH
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1648
Practice Address - Country:US
Practice Address - Phone:304-343-6219
Practice Address - Fax:304-343-1423
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11596174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0096789000Medicaid
WVMI9220052OtherMEDICARE GROUP NUMBER
WVB42588Medicare UPIN
WVMI0493184Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER