Provider Demographics
NPI:1508921651
Name:WIBBELS, LAWRENCE EVAN (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EVAN
Last Name:WIBBELS
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 1:2851 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-8123
Mailing Address - Country:US
Mailing Address - Phone:573-760-0097
Mailing Address - Fax:
Practice Address - Street 1:400 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2906
Practice Address - Country:US
Practice Address - Phone:573-756-8000
Practice Address - Fax:576-756-8288
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8G40261QA1903X
MOMDR8G40207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202404877Medicaid
MO000095126Medicare ID - Type Unspecified