Provider Demographics
NPI:1710935382
Name:CORYELL, LAWRENCE W (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:W
Last Name:CORYELL
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 1:804 SERVICE ROAD
Mailing Address - Street 2:ROOM A204
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7037
Mailing Address - Country:US
Mailing Address - Phone:517-353-4920
Mailing Address - Fax:
Practice Address - Street 1:804 SERVICE ROAD
Practice Address - Street 2:ROOM A204
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7037
Practice Address - Country:US
Practice Address - Phone:517-353-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010406972085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710935382Medicaid
MI4331905Medicaid
MIC36350032Medicare ID - Type Unspecified
D85020Medicare UPIN