Provider Demographics
NPI:1477543031
Name:GEOGHEGAN, LAWRENCE T (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:T
Last Name:GEOGHEGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:77 MASSACHUSETTS AVE
Mailing Address - Street 2:MIT MEDICAL DEPARTMENT E23-300
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4301
Mailing Address - Country:US
Mailing Address - Phone:617-253-4988
Mailing Address - Fax:617-253-7265
Practice Address - Street 1:77 MASSACHUSETTS AVE
Practice Address - Street 2:MIT MEDICAL DEPARTMENT E23-300
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4301
Practice Address - Country:US
Practice Address - Phone:617-253-4988
Practice Address - Fax:617-253-7265
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA30208208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0175161Medicaid
B33229OtherBCBS
LAM12968OtherBCBS
030208OtherTUFTS
MALAM12968Medicare ID - Type Unspecified
MAB33229Medicare ID - Type Unspecified
LAM12968OtherBCBS