Provider Demographics
NPI:1881675098
Name:DAVIS, LAWRENCE J (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:DAVIS
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 1:177 N DEAN ST
Mailing Address - Street 2:SUTIE 207
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2533
Mailing Address - Country:US
Mailing Address - Phone:201-567-0446
Mailing Address - Fax:
Practice Address - Street 1:177 N DEAN ST
Practice Address - Street 2:SUTIE 207
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2533
Practice Address - Country:US
Practice Address - Phone:201-567-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06641900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7449704Medicaid
NJ4122282OtherCIGNA
NJ0K8870OtherHEALTH NET
NJP801198OtherOXFORD HEALTH
NJP801198OtherOXFORD HEALTH
NJ7449704Medicaid