Provider Demographics
NPI:1285750182
Name:WADE, LAWRENCE DURELL (MD, LLC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DURELL
Last Name:WADE
Suffix:
Gender:M
Credentials:MD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 80780
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70898-0780
Mailing Address - Country:US
Mailing Address - Phone:225-928-3401
Mailing Address - Fax:225-928-9724
Practice Address - Street 1:3060 VALLEY CREEK DR.
Practice Address - Street 2:SUITE C
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:225-928-3401
Practice Address - Fax:225-928-9724
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD 03371R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1318531Medicaid
LA1318531Medicaid