Provider Demographics
NPI:1497958680
Name:CHARLES E. LAURENCE MD
Entity Type:Organization
Organization Name:CHARLES E. LAURENCE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-398-3464
Mailing Address - Street 1:1301 S MEDINA ST
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-3856
Mailing Address - Country:US
Mailing Address - Phone:512-398-3464
Mailing Address - Fax:512-398-6843
Practice Address - Street 1:1301 S MEDINA ST
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-3856
Practice Address - Country:US
Practice Address - Phone:512-398-3464
Practice Address - Fax:512-398-6843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID
TX=========OtherTAX ID
TXB24252Medicare UPIN