Provider Demographics
NPI:1881616241
Name:JOHNSON, LAWRENCE REVEL (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:REVEL
Last Name:JOHNSON
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 1:123 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-1004
Mailing Address - Country:US
Mailing Address - Phone:631-306-9808
Mailing Address - Fax:631-249-1920
Practice Address - Street 1:ICON PLC
Practice Address - Street 2:123 SMITH ST.
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735
Practice Address - Country:US
Practice Address - Phone:631-306-9808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296540207ZC0008X, 207ZI0100X, 207ZP0007X, 207ZP0102X, 207ZP0105X
OK23736207ZH0000X, 207ZP0102X
PAMD072950L207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZC0008XAllopathic & Osteopathic PhysiciansPathologyClinical Informatics
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathology
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200034920AMedicaid
OK2677Medicaid
OK2677Medicaid