Provider Demographics
NPI:1619977378
Name:HERBERHOLZ, LAWRENCE J (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:HERBERHOLZ
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 1:911 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-2509
Mailing Address - Country:US
Mailing Address - Phone:256-259-0185
Mailing Address - Fax:256-259-0317
Practice Address - Street 1:911 S BROAD ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2509
Practice Address - Country:US
Practice Address - Phone:256-259-0185
Practice Address - Fax:256-259-0317
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23961208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009990335Medicaid
AL529923150Medicaid
51524140OtherBLUE CROSS
51524140OtherBLUE CROSS
AL51524140Medicare PIN