Provider Demographics
NPI:1982789111
Name:DUBIN, LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:DUBIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:MARK
Other - Last Name:DUBIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 - 15TH AVE
Mailing Address - Street 2:STE 180
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-768-5430
Mailing Address - Fax:414-762-4225
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:STE #130
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-6053
Practice Address - Country:US
Practice Address - Phone:414-747-8856
Practice Address - Fax:414-747-6676
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI282262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68015-0020Medicare PIN
WI02120--0020Medicare PIN