Provider Demographics
NPI:1194719955
Name:TATUM, LAWRENCE G (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:G
Last Name:TATUM
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:PO BOX 12740
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2740
Mailing Address - Country:US
Mailing Address - Phone:562-468-0227
Mailing Address - Fax:
Practice Address - Street 1:111 DALLAS ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-1201
Practice Address - Country:US
Practice Address - Phone:210-495-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0873207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110553801Medicaid
TX8N2617OtherBCBS
TX110553804Medicaid
TX8N2617OtherBCBS
TX110553804Medicaid