Provider Demographics
NPI:1356347843
Name:EVANS, LAWRENCE GLENNON JR (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:GLENNON
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3824 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1237
Mailing Address - Country:US
Mailing Address - Phone:314-352-4400
Mailing Address - Fax:314-352-8496
Practice Address - Street 1:3824 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1237
Practice Address - Country:US
Practice Address - Phone:314-352-4400
Practice Address - Fax:314-352-8496
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO31680207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0900150OtherUNITED HEALTHCARE
MO21931OtherBLUE CROSS/BLUE SHIELD
MO49982OtherGROUP HEALTH PLAN GHP
MO009102OtherEXCLUSIVE CHOICE
MO100636OtherHEALTHLINK
MO200015590OtherMEDICARE RAILROAD
MO001011985Medicare ID - Type Unspecified
MO200015590OtherMEDICARE RAILROAD