Provider Demographics
NPI:1508890997
Name:SODERSTROM, LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:SODERSTROM
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 1:218 S HERLONG AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1158
Mailing Address - Country:US
Mailing Address - Phone:803-327-2828
Mailing Address - Fax:803-329-1173
Practice Address - Street 1:218 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1158
Practice Address - Country:US
Practice Address - Phone:803-327-2828
Practice Address - Fax:803-329-1173
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC228072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA2363Medicaid
SCC870081282Medicare PIN
SCC87008Medicare UPIN