Provider Demographics
NPI:1306133129
Name:LAWRENCE, ANDREW J (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1723 BROADWAY ST STE 315
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4556
Mailing Address - Country:US
Mailing Address - Phone:573-519-4960
Mailing Address - Fax:573-519-4655
Practice Address - Street 1:1723 BROADWAY ST STE 315
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4556
Practice Address - Country:US
Practice Address - Phone:573-519-4960
Practice Address - Fax:573-519-4655
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL33845207Q00000X
MO2015029582207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC17917043Medicare PIN