Healthcare Provider Details

I. General information

NPI: 1548310220
Provider Name (Legal Business Name): MATTHEW BRENT LAURENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

685 W BALTIMORE ST RM 480
BALTIMORE MD
21201-1509
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-5328
  • Fax: 410-706-1204
Mailing address:
  • Phone: 410-706-5328
  • Fax: 410-706-1204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD63115
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number63115
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberD63115
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: