Provider Demographics
NPI:1447233796
Name:ST. LAWRENCE, DALE G (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:G
Last Name:ST. LAWRENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST
Mailing Address - Street 2:WOT 2ND FL, STE C203
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-368-7887
Mailing Address - Fax:508-792-4392
Practice Address - Street 1:5 NEPONSET ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2714
Practice Address - Country:US
Practice Address - Phone:508-368-7887
Practice Address - Fax:508-792-4392
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74183208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110052104AMedicaid
784199OtherMVP HEALTH CARE
J13567OtherBLUE CARE ELECT
9900869OtherFALLON COMMUNITY HEALTH P
AA1180OtherHARVARD PILGRIM HEALTHCAR
27101OtherHEALTHY START
J13567OtherBLUE SHIELD IDEMNITY
W101220OtherCIGNA HEALTH PLAN
3548110OtherCIGNA HEALTHSOURCE
934663OtherFIRST HEALTH
9415679001OtherCIGNA PAL ID
27101OtherCHILDRENS MEDICAL SECURIT
J13567OtherBLUE SHIELD HMO BLUE
AA1180OtherHARVARD PILGRIM HEALTHCAR
F54262Medicare UPIN