Provider Demographics
NPI:1376568980
Name:WANG, LAWRENCE L (MD, PHD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:L
Last Name:WANG
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:#375-B
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2190
Mailing Address - Country:US
Mailing Address - Phone:314-842-5660
Mailing Address - Fax:314-842-0169
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:#375-B
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2190
Practice Address - Country:US
Practice Address - Phone:314-842-5660
Practice Address - Fax:314-842-0169
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005004447207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000010459Medicare PIN
MOI31348Medicare UPIN
MO931310459Medicare ID - Type Unspecified