Provider Demographics
NPI:1437269347
Name:PENVOSE, LAWRENCE CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:CHARLES
Last Name:PENVOSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 HARRISON AVE NW STE 105
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2634
Mailing Address - Country:US
Mailing Address - Phone:330-455-4531
Mailing Address - Fax:330-455-0119
Practice Address - Street 1:1445 HARRISON AVENUE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708
Practice Address - Country:US
Practice Address - Phone:330-455-4531
Practice Address - Fax:330-455-0119
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004573207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0821267Medicaid
PE0692571Medicare ID - Type Unspecified
E84844Medicare UPIN