Provider Demographics
NPI:1790843316
Name:WYNER, LAWRENCE M (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:WYNER
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 1:1115 20TH STREET
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703
Mailing Address - Country:US
Mailing Address - Phone:304-691-1900
Mailing Address - Fax:304-691-1929
Practice Address - Street 1:1115 20TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-2071
Practice Address - Country:US
Practice Address - Phone:304-691-1900
Practice Address - Fax:304-691-1929
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059870208800000X
WV16680208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0130195000Medicaid
WV0130195000Medicaid
E65532Medicare UPIN