Provider Demographics
NPI:1760430003
Name:POWELL, LAWRENCE DONALD (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:DONALD
Last Name:POWELL
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 1:720 WESTVIEW DR SW
Mailing Address - Street 2:SUITE 100-A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1458
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:404-756-1402
Practice Address - Street 1:1595 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3200
Practice Address - Country:US
Practice Address - Phone:404-616-2886
Practice Address - Fax:404-209-1769
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038915207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000652198IMedicaid
GA08652198Medicaid
GA000652198HMedicaid
GA511I080213Medicare UPIN
GAF96074Medicare UPIN
GA08652198Medicaid
GA000652198HMedicaid
GA202I080862Medicare UPIN
GA08BDHLCMedicare ID - Type Unspecified