Provider Demographics
NPI:1588654651
Name:LAWRENCE, MARCELLUS R (MD)
Entity Type:Individual
Prefix:MR
First Name:MARCELLUS
Middle Name:R
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12303 DE PAUL DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2512
Mailing Address - Country:US
Mailing Address - Phone:314-344-7049
Mailing Address - Fax:314-344-7073
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-7049
Practice Address - Fax:314-344-7073
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOMDRJ33207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D40415Medicare UPIN
MO08012694Medicare ID - Type Unspecified