Provider Demographics
NPI:1881962462
Name:WIWATOWSKI, LAURENCE JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:JOHN
Last Name:WIWATOWSKI
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 1:1416 W CHERRYWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-2999
Mailing Address - Country:US
Mailing Address - Phone:509-466-2767
Mailing Address - Fax:
Practice Address - Street 1:1416 W CHERRYWOOD CT
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-2999
Practice Address - Country:US
Practice Address - Phone:509-466-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00011228174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist