Provider Demographics
NPI:1891790192
Name:WAYBURN, LAWRENCE G (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:G
Last Name:WAYBURN
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 1:2 BIG BEAR PL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508
Mailing Address - Country:US
Mailing Address - Phone:989-928-2397
Mailing Address - Fax:505-471-4388
Practice Address - Street 1:2 BIG BEAR PL
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508
Practice Address - Country:US
Practice Address - Phone:989-928-2397
Practice Address - Fax:505-471-4388
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-02432085R0202X
MI43010385772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891790192OtherNPI
NM51282551Medicaid
MI4542150Medicaid
MI4542150Medicaid
NM51282551Medicaid