Provider Demographics
NPI:1659572527
Name:UDOM, LAWRENCE E (MD, MPH)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:E
Last Name:UDOM
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 COMMONS BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3834
Mailing Address - Country:US
Mailing Address - Phone:937-425-4015
Mailing Address - Fax:937-425-4014
Practice Address - Street 1:2510 COMMONS BLVD STE 160
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3834
Practice Address - Country:US
Practice Address - Phone:937-425-4015
Practice Address - Fax:937-425-4014
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35095926207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0051288Medicaid
OHH008460Medicare PIN