Provider Demographics
NPI:1417953373
Name:LAWRENCE, JOSEPH J (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 638
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717
Mailing Address - Country:US
Mailing Address - Phone:307-682-3078
Mailing Address - Fax:307-687-7243
Practice Address - Street 1:501 SO. BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716
Practice Address - Country:US
Practice Address - Phone:307-688-1600
Practice Address - Fax:307-687-7243
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5119A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F30994Medicare UPIN
WY306005Medicare ID - Type Unspecified