Provider Demographics
NPI:1104896794
Name:LAWENDA, BRIAN DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:LAWENDA
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 1:3080 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6720
Mailing Address - Country:US
Mailing Address - Phone:941-883-2199
Mailing Address - Fax:941-979-5041
Practice Address - Street 1:8026 S TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293
Practice Address - Country:US
Practice Address - Phone:941-220-6460
Practice Address - Fax:941-220-5284
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA871772085R0001X
NV134332085R0001X
WAMD606225892085R0001X
FLME1678332085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4738395OtherCIGNA
WA1104896794Medicaid
NV1457283OtherGHI
NV01371595OtherAMERIGROUP
FL122055900Medicaid
NV7839863OtherAETNA
WAP01650856OtherRR MEDICARE
WA7839863OtherAETNA
P00894440OtherRAILROAD MEDICARE
NV1104896794Medicaid
OR500708662Medicaid
AZ518641Medicaid
WAG8952020Medicare PIN