Provider Demographics
NPI:1184913147
Name:LAWRENCE, JERRY L (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:LAWRENCE
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 1:11705 NW TIMBERVIEW LN
Mailing Address - Street 2:APT 204
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6659
Mailing Address - Country:US
Mailing Address - Phone:303-815-8764
Mailing Address - Fax:
Practice Address - Street 1:11705 NW TIMBERVIEW LN
Practice Address - Street 2:APT 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-6659
Practice Address - Country:US
Practice Address - Phone:303-815-8764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01071935A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201100990Medicaid
IN201100990Medicaid