Provider Demographics
NPI:1629340443
Name:THACKSTON, LAWRENCE PHILLIPS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:PHILLIPS
Last Name:THACKSTON
Suffix:JR
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 1:646 RIVERS TURN ROAD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115
Mailing Address - Country:US
Mailing Address - Phone:803-536-0511
Mailing Address - Fax:
Practice Address - Street 1:646 RIVERS TURN ROAD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115
Practice Address - Country:US
Practice Address - Phone:803-536-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD4125208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology