Provider Demographics
NPI:1700994423
Name:WANG, LAWRENCE C (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:C
Last Name:WANG
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 1:3245 INTERNATIONAL CIR STE 103
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3152
Mailing Address - Country:US
Mailing Address - Phone:719-447-0150
Mailing Address - Fax:719-355-1435
Practice Address - Street 1:3245 INTERNATIONAL CIR STE 103
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3152
Practice Address - Country:US
Practice Address - Phone:719-447-0150
Practice Address - Fax:719-355-1435
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2010-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO407412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80734324Medicaid
F66698Medicare UPIN
CO80734324Medicaid