Provider Demographics
NPI:1376684878
Name:LORENZ, LANDON BERNHARDT (MD)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:BERNHARDT
Last Name:LORENZ
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 1:201 WALLS DR STE 503
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4006
Mailing Address - Country:US
Mailing Address - Phone:817-984-9057
Mailing Address - Fax:
Practice Address - Street 1:201 WALLS DR STE 503
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4006
Practice Address - Country:US
Practice Address - Phone:817-984-9057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23983207V00000X
TXR3555207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1427182682OtherGROUP NPI
NMNM001M59OtherBCBS PROVIDER ID
AZ343208Medicaid
NMMD2008-0332OtherNEW MEXICO STATE LICENSE
NMNM300626Medicare PIN