Healthcare Provider Details

I. General information

NPI: 1205823945
Provider Name (Legal Business Name): LAWRENCE W GAUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S THOMPSON ST
FLAGSTAFF AZ
86001-8759
US

IV. Provider business mailing address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-226-6400
  • Fax: 928-226-6401
Mailing address:
  • Phone: 928-213-6235
  • Fax: 928-213-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number61923
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number32738
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: