Provider Demographics
NPI:1245273812
Name:SO, LAURENCE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:
Last Name:SO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURENCE
Other - Middle Name:S
Other - Last Name:SO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1000 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7694
Mailing Address - Country:US
Mailing Address - Phone:678-312-3294
Mailing Address - Fax:678-312-3282
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-3294
Practice Address - Fax:678-312-3282
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072131207R00000X
NC200100468207R00000X
GA72131208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1245273812Medicaid
NC8912824Medicaid
SCNC1992Medicaid
SCNC1992Medicaid
NC1245273812Medicaid
NCH34653Medicare UPIN