Provider Demographics
NPI:1194775163
Name:WOLPERT, LAURENCE A (DO)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:A
Last Name:WOLPERT
Suffix:
Gender:M
Credentials:DO
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 31370
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-0370
Mailing Address - Country:US
Mailing Address - Phone:402-551-6275
Mailing Address - Fax:
Practice Address - Street 1:1005 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68132-1115
Practice Address - Country:US
Practice Address - Phone:402-551-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5733207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6005220Medicaid
SD6005220Medicaid
SDF77995Medicare UPIN