Healthcare Provider Details

I. General information

NPI: 1770589103
Provider Name (Legal Business Name): LAWRENCE LARAY GIPSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MCKEAN AVE
CHARLEROI PA
15022-1416
US

IV. Provider business mailing address

PO BOX 212
CHARLEROI PA
15022-0212
US

V. Phone/Fax

Practice location:
  • Phone: 724-483-8065
  • Fax: 724-565-5110
Mailing address:
  • Phone: 724-483-8065
  • Fax: 724-565-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD020526E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: