Healthcare Provider Details

I. General information

NPI: 1770005951
Provider Name (Legal Business Name): MATTHEW W LAWRENCE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BREWSTER ST
PAWTUCKET RI
02860-4474
US

IV. Provider business mailing address

630 SMITHFIELD RD APT 410
NORTH PROVIDENCE RI
02904-2928
US

V. Phone/Fax

Practice location:
  • Phone: 401-729-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberLPR00180
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: