Provider Demographics
NPI:1154380806
Name:WEINBERG, LAURENCE M (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:M
Last Name:WEINBERG
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 1:1691 GALISTEO STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-983-5631
Mailing Address - Fax:505-982-5605
Practice Address - Street 1:1691 GALISTEO ST
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4780
Practice Address - Country:US
Practice Address - Phone:505-983-5631
Practice Address - Fax:505-982-5605
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD20090086207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010652890003Medicaid
D71356Medicare UPIN
PA0010652890003Medicaid