Healthcare Provider Details

I. General information

NPI: 1578778585
Provider Name (Legal Business Name): LAWRENCE VIDAVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2007
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 LARRYVALE RD
BALTIMORE MD
21209-3206
US

IV. Provider business mailing address

2506 LARRYVALE RD
BALTIMORE MD
21209-3206
US

V. Phone/Fax

Practice location:
  • Phone: 410-848-8202
  • Fax: 410-848-2644
Mailing address:
  • Phone: 410-848-8202
  • Fax: 410-848-2644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number025559
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: