Provider Demographics
NPI:1265590251
Name:WHALEN, LAWRENCE PETER
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:PETER
Last Name:WHALEN
Suffix:
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 1:78 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-1233
Mailing Address - Country:US
Mailing Address - Phone:413-584-8212
Mailing Address - Fax:413-584-8212
Practice Address - Street 1:78 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MA
Practice Address - Zip Code:01062-1233
Practice Address - Country:US
Practice Address - Phone:413-584-8212
Practice Address - Fax:413-584-8212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1799156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1517775Medicaid
MA1517775Medicaid