Provider Demographics
NPI:1427055813
Name:LAWRENCE, THOMAS L (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:LAWRENCE
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 1:6635 COMANCHE ST
Mailing Address - Street 2:PO BOX Q
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7523
Mailing Address - Country:US
Mailing Address - Phone:208-267-1718
Mailing Address - Fax:208-267-7739
Practice Address - Street 1:1327 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1735
Practice Address - Country:US
Practice Address - Phone:208-263-7101
Practice Address - Fax:208-263-7198
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002792500Medicaid
ID806590100Medicaid
ID806590100Medicaid
ID131832Medicare Oscar/Certification
IDC47813Medicare UPIN