Provider Demographics
NPI:1235109174
Name:NIVALA, LAWRENCE WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:WILLIAM
Last Name:NIVALA
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 1:114 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-2903
Mailing Address - Country:US
Mailing Address - Phone:360-452-2361
Mailing Address - Fax:360-452-2362
Practice Address - Street 1:114 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-2903
Practice Address - Country:US
Practice Address - Phone:360-452-2361
Practice Address - Fax:360-452-2362
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD2046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2025120Medicaid
WA2025120Medicaid
WAAB24252Medicare ID - Type Unspecified