Provider Demographics
NPI:1972565448
Name:RICHARD, LAWRENCE B (DPM)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:B
Last Name:RICHARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22908 WICK RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3589
Mailing Address - Country:US
Mailing Address - Phone:313-295-2660
Mailing Address - Fax:313-295-1878
Practice Address - Street 1:22908 WICK RD
Practice Address - Street 2:SUITE C
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3589
Practice Address - Country:US
Practice Address - Phone:313-295-2660
Practice Address - Fax:313-295-1878
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001176213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2845097Medicaid
MI480006260OtherMR RR TAYLOR
MI4858255610OtherBCBSM TLR
MI480011674OtherRAILROAD MEDICARE
MI1658287Medicaid
MI480D710100OtherBCBSM GROUP HWL
MI1717566Medicaid
MI480F302060OtherBCBSM GROUP SLD
MI480006260OtherMR RR TAYLOR
MI1717566Medicaid
MIT91553Medicare UPIN
MI2845097Medicaid
MI1186930001Medicare NSC