Provider Demographics
NPI:1376529511
Name:LAWRENCE, GARY MONROE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MONROE
Last Name:LAWRENCE
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 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:1919 E MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-1253
Practice Address - Country:US
Practice Address - Phone:405-341-7009
Practice Address - Fax:405-330-1811
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100135780BOtherSOONERCARE
OK100135780AMedicaid
OKD42572Medicare UPIN