Provider Demographics
NPI:1508958521
Name:JEDLICKA, LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:JEDLICKA
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 1:4001 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5300
Mailing Address - Country:US
Mailing Address - Phone:907-677-1012
Mailing Address - Fax:907-565-6001
Practice Address - Street 1:4001 LAUREL ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5300
Practice Address - Country:US
Practice Address - Phone:907-677-1012
Practice Address - Fax:907-565-6001
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069361207RA0401X
MS223782084N0400X
KY431032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E54873Medicare UPIN