Basic Information
Provider Information | |||||||||
NPI: | 1699770255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAWRENCE | ||||||||
FirstName: | MARVIN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12510 PROSPERITY DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SILVER SPRING | ||||||||
State: | MD | ||||||||
PostalCode: | 209041663 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2404855200 | ||||||||
FaxNumber: | 3016256906 | ||||||||
Practice Location | |||||||||
Address1: | 7350 VAN DUSEN RD | ||||||||
Address2: | STE 210 | ||||||||
City: | LAUREL | ||||||||
State: | MD | ||||||||
PostalCode: | 207075268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3014985500 | ||||||||
FaxNumber: | 3014987346 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2005 | ||||||||
LastUpdateDate: | 07/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | D0058872 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 616770-01 | 01 | MD | CAREFIRST BSMD | OTHER | A1110002 | 01 | DC | CAREFIRST BCBS DC | OTHER | N5630033 | 01 | MD | CAREFIRST MD/DC | OTHER | 100016445 | 01 | MD | RAILROAD MEDICARE | OTHER | A1130003 | 01 | DC | CAREFIRST BCBS DC | OTHER | 2516-0006 | 01 | DC | CAREFIRST BSDC | OTHER | P00679062 | 01 | MD | RAILROAD MEDICARE | OTHER | 510101800 | 05 | MD |   | MEDICAID |