Provider Demographics
NPI:1356367296
Name:SMALL, LAWRENCE W (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:W
Last Name:SMALL
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:PO BOX 2946
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77305
Mailing Address - Country:US
Mailing Address - Phone:936-291-0900
Mailing Address - Fax:936-291-0955
Practice Address - Street 1:521 INTERSTATE 45 SOUTH
Practice Address - Street 2:STE 12
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340
Practice Address - Country:US
Practice Address - Phone:936-291-0900
Practice Address - Fax:936-291-0955
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8915207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00010410OtherMCR RAILROAD
TX0053JPOtherBLUE CROSS BLUE SHIELD
TX0053JPOtherBLUE CROSS BLUE SHIELD
C21904Medicare UPIN