Provider Demographics
NPI:1508814450
Name:CRYSTAL, LAWRENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:CRYSTAL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 MILL ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:ME
Mailing Address - Zip Code:04668-3344
Mailing Address - Country:US
Mailing Address - Phone:207-796-5503
Mailing Address - Fax:207-796-5528
Practice Address - Street 1:136 MILL ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:ME
Practice Address - Zip Code:04668-3344
Practice Address - Country:US
Practice Address - Phone:207-796-5503
Practice Address - Fax:207-796-5528
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD153213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME111430000Medicaid
ME48007894OtherRAILROAD MEDICARE PROV #
ME098463OtherANTHEM IDENTIFICATION
ME2183024OtherAETNA PROV #
ME48007894OtherRAILROAD MEDICARE PROV #
ME111430000Medicaid
MEMM015203Medicare PIN