MEDICARE: DR. LAWRENCE WILLIAM NIVALA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OD2046	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235109174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE WILLIAM NIVALA O.D.

Provider Business Mailing Address
First Line	:	114 E 1ST ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-2903
Country	:	US
Telephone Number	:	360-452-2361
Fax Number	:	360-452-2362

Provider Business Practice Location Address
First Line	:	114 E 1ST ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-2903
Country	:	US
Telephone Number	:	360-452-2361
Fax Number	:	360-452-2362

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	02/19/2014

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