Provider Demographics
NPI:1275733560
Name:EIDT, LAURENCE A (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:A
Last Name:EIDT
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 1:1012 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328-1606
Mailing Address - Country:US
Mailing Address - Phone:509-382-2531
Mailing Address - Fax:509-382-3209
Practice Address - Street 1:1012 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328-1606
Practice Address - Country:US
Practice Address - Phone:509-382-2531
Practice Address - Fax:509-382-3209
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAD16919Medicare UPIN