Healthcare Provider Details

I. General information

NPI: 1528383130
Provider Name (Legal Business Name): CONRAD M LAWRENCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 W SOUTHERN AVE BLDG. B10
APACHE JUNCTION AZ
85120-7455
US

IV. Provider business mailing address

PO BOX 10097
CASA GRANDE AZ
85130-0020
US

V. Phone/Fax

Practice location:
  • Phone: 480-351-2850
  • Fax: 480-351-2851
Mailing address:
  • Phone: 480-351-2850
  • Fax: 480-351-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48947
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: