Provider Demographics
NPI:1992763585
Name:NORTHORN, LAWRENCE L (DO)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:L
Last Name:NORTHORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2600
Mailing Address - Country:US
Mailing Address - Phone:631-581-0090
Mailing Address - Fax:631-581-0090
Practice Address - Street 1:126 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2600
Practice Address - Country:US
Practice Address - Phone:631-581-0090
Practice Address - Fax:631-581-2879
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A400008625Medicare PIN