Provider Demographics
NPI:1992966295
Name:LAWRENCE, BRENT MARTELL (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:MARTELL
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 1:800 EXCHANGE AVE STE 102B
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-7833
Mailing Address - Country:US
Mailing Address - Phone:501-504-6994
Mailing Address - Fax:501-504-6985
Practice Address - Street 1:800 EXCHANGE AVE STE 102B
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7833
Practice Address - Country:US
Practice Address - Phone:501-504-6994
Practice Address - Fax:501-504-6985
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE8177207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206117001Medicaid
370913ZG8EOtherMEDICARE PTAN
AR5I434OtherBCBS