Provider Demographics
NPI:1174644710
Name:IRENE, LAWRENCE M (OD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:IRENE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 S ARIZONA MILLS CIR STE 165
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-6417
Mailing Address - Country:US
Mailing Address - Phone:480-820-3813
Mailing Address - Fax:
Practice Address - Street 1:5000 S ARIZONA MILLS CIR STE 165
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-6417
Practice Address - Country:US
Practice Address - Phone:480-820-3813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ811152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU55417Medicare UPIN
AZOD811Medicare ID - Type Unspecified