Provider Demographics
NPI:1942207733
Name:DIDOMENICO, LAWRENCE (DPM)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:DIDOMENICO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-626-6161
Mailing Address - Fax:419-502-3511
Practice Address - Street 1:8175 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6244
Practice Address - Country:US
Practice Address - Phone:330-629-8800
Practice Address - Fax:330-758-4914
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV236213E00000X
PASC-00-3181213E00000X
OH36-00-2513213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02513OtherTHE HEALTH PLAN
WV6420012Medicaid
PA01145989Medicaid
WV1013181-1045507OtherWORKERS COMP
4117771OtherAETNA
OH0712232Medicaid
539836OtherHIGHMARK
0624936Medicare ID - Type Unspecified
0624931Medicare ID - Type Unspecified
0865795Medicare ID - Type Unspecified
0624938Medicare ID - Type Unspecified
PA01145989Medicaid
0865793Medicare ID - Type Unspecified
WV6420012Medicaid
WV1013181-1045507OtherWORKERS COMP
0865794Medicare ID - Type Unspecified
WV4060801Medicare ID - Type Unspecified
OHT96116Medicare UPIN