Healthcare Provider Details

I. General information

NPI: 1881689099
Provider Name (Legal Business Name): KEVIN LAWRENCE LASER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 BENFOREST DR
SEVERNA PARK MD
21146-1735
US

IV. Provider business mailing address

512 BENFOREST DR
SEVERNA PARK MD
21146-1735
US

V. Phone/Fax

Practice location:
  • Phone: 410-544-7611
  • Fax: 410-544-5179
Mailing address:
  • Phone: 410-544-7611
  • Fax: 410-544-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD35560
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: