Provider Demographics
NPI:1770526097
Name:PLUMB, LAURENCE ROGER (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:ROGER
Last Name:PLUMB
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 1:5037 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5720
Mailing Address - Country:US
Mailing Address - Phone:716-560-9995
Mailing Address - Fax:866-253-5222
Practice Address - Street 1:5037 LAKE SHORE RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-5720
Practice Address - Country:US
Practice Address - Phone:716-560-9995
Practice Address - Fax:866-253-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00720810Medicaid
CC8289Medicare ID - Type Unspecified
NY00720810Medicaid