Provider Demographics
NPI:1811925381
Name:MACIOLEK, LAWRENCE JOHN (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:JOHN
Last Name:MACIOLEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:575 W RIVER WOODS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1003
Mailing Address - Country:US
Mailing Address - Phone:414-332-6262
Mailing Address - Fax:414-332-0422
Practice Address - Street 1:525 W RIVER WOODS PARKWAY
Practice Address - Street 2:SUITE 130
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-961-0304
Practice Address - Fax:414-961-2061
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45567-020207X00000X
WI45567-20207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34908400Medicaid