Provider Demographics
NPI:1306003512
Name:LIBENGOOD, LAWRENCE WALTER III (IDC)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:WALTER
Last Name:LIBENGOOD
Suffix:III
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D LAAD BN DET A
Mailing Address - Street 2:H&S BATTERY UNIT 78087
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09509-8087
Mailing Address - Country:US
Mailing Address - Phone:318-342-2177
Mailing Address - Fax:
Practice Address - Street 1:2D LAAD BN DET A
Practice Address - Street 2:UNIT 78087 H&S BATTERY
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09509-8087
Practice Address - Country:US
Practice Address - Phone:318-342-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman