Provider Demographics
NPI:1285627208
Name:LAWRENCE, KENNETH E
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:
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 269
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-0269
Mailing Address - Country:US
Mailing Address - Phone:574-753-2559
Mailing Address - Fax:574-722-4926
Practice Address - Street 1:216 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-3430
Practice Address - Country:US
Practice Address - Phone:574-753-2559
Practice Address - Fax:574-722-4926
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001980B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000085953OtherBCBS
IN100070790Medicaid
IN100070790Medicaid
IN0181920001Medicare NSC
IN111930Medicare ID - Type Unspecified