Provider Demographics
NPI:1831176551
Name:PIVNICK, LAWRENCE N (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:N
Last Name:PIVNICK
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 1:10 MEDICAL PKWY STE 206
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7845
Mailing Address - Country:US
Mailing Address - Phone:972-247-3262
Mailing Address - Fax:972-247-1406
Practice Address - Street 1:10 MEDICAL PKWY STE 206
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7845
Practice Address - Country:US
Practice Address - Phone:972-247-3262
Practice Address - Fax:972-247-1406
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032493102Medicaid
TX032493103Medicaid
TX8L2136Medicare PIN
TXB25539Medicare UPIN
TX8G8013Medicare ID - Type Unspecified
TX032493103Medicaid