Provider Demographics
NPI:1124067632
Name:LAWRENCE, WALTER J (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:J
Last Name:LAWRENCE
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 1:551 GLOVER AVE
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2041
Mailing Address - Country:US
Mailing Address - Phone:334-475-2058
Mailing Address - Fax:334-489-4308
Practice Address - Street 1:551 GLOVER AVE
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2041
Practice Address - Country:US
Practice Address - Phone:334-475-2058
Practice Address - Fax:334-489-4308
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009975885Medicaid
AL51000284OtherBLUE CROSS BLUE SHIELD
H92766Medicare UPIN
AL009975885Medicaid
AL051555277Medicare PIN