Healthcare Provider Details

I. General information

NPI: 1790772614
Provider Name (Legal Business Name): TODD K LAWRENCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVE
WATERLOO IA
50703
US

IV. Provider business mailing address

1825 LOGAN AVE
WATERLOO IA
50703-1916
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 319-235-3697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34751
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34751
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: