Provider Demographics
NPI:1780673988
Name:D'AMICO, LAWRENCE M (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:D'AMICO
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 1:8601 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2347
Mailing Address - Country:US
Mailing Address - Phone:330-856-6201
Mailing Address - Fax:330-856-6349
Practice Address - Street 1:8601 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2347
Practice Address - Country:US
Practice Address - Phone:330-856-6201
Practice Address - Fax:330-856-6349
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-6355174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0976485Medicaid
OH0976485Medicaid
OHF87083Medicare UPIN
OHD 0764681Medicare ID - Type Unspecified