Provider Demographics
NPI:1588609408
Name:MACTAVISH, LAWRENCE SCOTT (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:SCOTT
Last Name:MACTAVISH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:17215 RED OAK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2697
Mailing Address - Country:US
Mailing Address - Phone:281-444-4114
Mailing Address - Fax:281-444-7789
Practice Address - Street 1:17215 RED OAK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2697
Practice Address - Country:US
Practice Address - Phone:281-444-4114
Practice Address - Fax:281-444-7789
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX506213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121574101Medicaid
TX121574103Medicaid
TX480006483OtherRR MEDICARE
TX8W6250OtherBCBS
TX00J24POtherBCBS
TX480029262OtherRR MEDICARE
TX121574103Medicaid
TX00J24POtherBCBS
TXT14537Medicare UPIN
TX82663NMedicare PIN
TX8K5256Medicare PIN