Provider Demographics
NPI:1285641001
Name:LAURENCE, CHARLES EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWIN
Last Name:LAURENCE
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 1:1301 SOUTH MEDINA
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644
Mailing Address - Country:US
Mailing Address - Phone:512-398-3464
Mailing Address - Fax:512-398-6843
Practice Address - Street 1:1301 SOUTH MEDINA
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644
Practice Address - Country:US
Practice Address - Phone:512-398-3464
Practice Address - Fax:512-398-6843
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2010-12-30
Deactivation Date:2007-07-24
Deactivation Code:
Reactivation Date:2008-02-11
Provider Licenses
StateLicense IDTaxonomies
TXG1943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742237082OtherTAX ID
TX742237082OtherTAX ID
TX00SC20Medicare PIN