Provider Demographics
NPI:1710960596
Name:ALTAKER, LAWRENCE L (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:L
Last Name:ALTAKER
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 1:1013 MUMMA RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WORMLEYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1144
Mailing Address - Country:US
Mailing Address - Phone:717-761-6147
Mailing Address - Fax:717-731-8712
Practice Address - Street 1:1013 MUMMA RD
Practice Address - Street 2:SUITE 203
Practice Address - City:WORMLEYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17043-1144
Practice Address - Country:US
Practice Address - Phone:717-761-6147
Practice Address - Fax:717-731-8712
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD007139E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010017280002Medicaid
PA65359Medicare ID - Type Unspecified
PAB34725Medicare UPIN