Provider Demographics
NPI:1265165039
Name:JEFFERSON, LAWERENCE JOSEPH II
Entity type:Individual
Prefix:MR
First Name:LAWERENCE
Middle Name:JOSEPH
Last Name:JEFFERSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10317 TULIP TREE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3704
Mailing Address - Country:US
Mailing Address - Phone:240-602-7730
Mailing Address - Fax:
Practice Address - Street 1:114 WAYNE PL SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-6119
Practice Address - Country:US
Practice Address - Phone:202-768-2646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC172V00000X
MDT24909183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No172V00000XOther Service ProvidersCommunity Health Worker