Provider Demographics
NPI:1578561122
Name:WAITE, LAWRENCE JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JOHN
Last Name:WAITE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2621
Mailing Address - Country:US
Mailing Address - Phone:607-733-2694
Mailing Address - Fax:607-733-1139
Practice Address - Street 1:382 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2621
Practice Address - Country:US
Practice Address - Phone:607-733-2694
Practice Address - Fax:607-733-1139
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV4209-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYOVS71OtherBC&BS
40005BMedicare UPIN
NYOVS71OtherBC&BS