Provider Demographics
NPI:1891756763
Name:WALLIN, LAWRENCE A (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
Last Name:WALLIN
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 1:2019 NORMANDIE DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2711
Mailing Address - Country:US
Mailing Address - Phone:334-281-7523
Mailing Address - Fax:334-281-7912
Practice Address - Street 1:2019 NORMANDIE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2711
Practice Address - Country:US
Practice Address - Phone:334-281-7523
Practice Address - Fax:334-281-7912
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL187122080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL23675OtherBLUE CROSS OF AL
E15036Medicare UPIN