Provider Demographics
NPI:1306922885
Name:BROUWER, LAWRENCE DALE (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:DALE
Last Name:BROUWER
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 1:411 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2470
Mailing Address - Country:US
Mailing Address - Phone:406-363-5104
Mailing Address - Fax:406-363-2894
Practice Address - Street 1:411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2470
Practice Address - Country:US
Practice Address - Phone:406-363-5104
Practice Address - Fax:406-363-2894
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTA002OtherTRICARE
MT0069134Medicaid
MT0069134Medicaid