Provider Demographics
NPI:1205194727
Name:KETTWICH, LAWRENCE G (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:G
Last Name:KETTWICH
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 1:2825 STOCKYARD RD
Mailing Address - Street 2:BLDG I-200
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808
Mailing Address - Country:US
Mailing Address - Phone:406-728-8420
Mailing Address - Fax:406-541-8430
Practice Address - Street 1:2825 STOCKYARD RD STE I-200
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1548
Practice Address - Country:US
Practice Address - Phone:406-728-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-0071207L00000X
MTMED-PHYS-LIC-55728207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTMED-PHYS-LIC-55728OtherMONTANA MEDICAL LICENSE