Provider Demographics
NPI:1508844366
Name:SHALL, LAWRENCE M (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:SHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 CLEARFIELD AVE.
Mailing Address - Street 2:SUITE #124
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:733 VOLVO PKWY
Practice Address - Street 2:SUITE # 300
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1609
Practice Address - Country:US
Practice Address - Phone:757-321-3383
Practice Address - Fax:757-321-3332
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040335207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C00101OtherMEDICARE LEGACY GROUP
VA006496997Medicaid
CC7688OtherRAILROAD MEDICARE GROUP#
200030046OtherRAILROAD MEDICARE
200030046OtherRAILROAD MEDICARE
VA006496997Medicaid