Provider Demographics
NPI:1457458549
Name:PETERS, LAWRENCE STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:STEPHEN
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:#305
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-751-5763
Mailing Address - Fax:703-370-8704
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:#305
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-751-5763
Practice Address - Fax:703-370-8704
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027484207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6079954Medicaid
VAC87770Medicare UPIN
VA119869D12Medicare ID - Type Unspecified