Healthcare Provider Details

I. General information

NPI: 1104858885
Provider Name (Legal Business Name): LAWRENCE SCOTT MACTAVISH II D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17215 RED OAK DR STE 102
HOUSTON TX
77090-2611
US

IV. Provider business mailing address

17215 RED OAK DR STE 102
HOUSTON TX
77090-2611
US

V. Phone/Fax

Practice location:
  • Phone: 281-444-4114
  • Fax: 281-453-1269
Mailing address:
  • Phone: 281-444-4114
  • Fax: 281-453-1269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1715
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: