Healthcare Provider Details

I. General information

NPI: 1194963454
Provider Name (Legal Business Name): LAWRENCE WAYNE SHIVERTAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2009
Last Update Date: 01/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2486 SHALIMAR LN
ORANGE PARK FL
32073-6123
US

IV. Provider business mailing address

2486 SHALIMAR LN
ORANGE PARK FL
32073-6123
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-5274
  • Fax:
Mailing address:
  • Phone: 904-269-5274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License NumberME60157
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: