Provider Demographics
NPI:1306922315
Name:LAUTERBACH, EDWARD C (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:LAUTERBACH
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 1:1550 COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-1554
Mailing Address - Country:US
Mailing Address - Phone:478-301-4111
Mailing Address - Fax:478-301-2387
Practice Address - Street 1:940 HWY 96
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-988-1222
Practice Address - Fax:478-988-1106
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0310562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000383908AMedicaid
GA260022713OtherRAILROAD MEDICARE
GA260022713OtherRAILROAD MEDICARE
GA000383908AMedicaid