Provider Demographics
NPI:1730111782
Name:WARREN, LAWRENCE (DPM)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:WARREN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-3800
Mailing Address - Country:US
Mailing Address - Phone:817-921-5339
Mailing Address - Fax:
Practice Address - Street 1:3109 6TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-3800
Practice Address - Country:US
Practice Address - Phone:817-921-5339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0465213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018790801Medicaid
TX8AJ098OtherBLUE CROSS BLUE SHIELD
TX8F8751OtherMEDICARE
TX6298930001Medicare NSC
TX018790801Medicaid