Provider Demographics
NPI:1932193554
Name:LUM, LAURENCE (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:
Last Name:LUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N STATE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-3052
Mailing Address - Country:US
Mailing Address - Phone:573-431-4449
Mailing Address - Fax:573-431-2443
Practice Address - Street 1:330 N STATE ST
Practice Address - Street 2:SUITE C
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-3052
Practice Address - Country:US
Practice Address - Phone:573-431-4449
Practice Address - Fax:573-431-2443
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOBL4277059OtherDEA
MOGO2436Medicare UPIN
MOBL4277059OtherDEA