Provider Demographics
NPI:1184699431
Name:DEBARGE, LAWRENCE RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:RAYMOND
Last Name:DEBARGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L.
Other - Middle Name:RAYMOND
Other - Last Name:DEBARGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:200 WILDWOOD PKWY STE 100B
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-7300
Mailing Address - Country:US
Mailing Address - Phone:205-943-4650
Mailing Address - Fax:205-943-4688
Practice Address - Street 1:304 PARKS AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2412
Practice Address - Country:US
Practice Address - Phone:256-259-6507
Practice Address - Fax:256-533-8803
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN017365207W00000X, 207WX0108X
GA035850207W00000X
ALMD.45170207WX0108X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3069468Medicare PIN
GA18BDCZBMedicare PIN
GAF33155Medicare UPIN