Provider Demographics
NPI:1679559603
Name:VIDRINE, LAWRENCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ROBERT
Last Name:VIDRINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3705 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-6127
Mailing Address - Country:US
Mailing Address - Phone:253-759-2134
Mailing Address - Fax:
Practice Address - Street 1:11367 BRIDGEPORT WAY SW
Practice Address - Street 2:SUITE 217
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3004
Practice Address - Country:US
Practice Address - Phone:253-985-6134
Practice Address - Fax:253-985-6137
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00022122208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology