Healthcare Provider Details

I. General information

NPI: 1285641001
Provider Name (Legal Business Name): CHARLES EDWIN LAURENCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date: 07/24/2007
Reactivation Date: 02/11/2008

III. Provider practice location address

1301 SOUTH MEDINA
LOCKHART TX
78644
US

IV. Provider business mailing address

1301 SOUTH MEDINA
LOCKHART TX
78644
US

V. Phone/Fax

Practice location:
  • Phone: 512-398-3464
  • Fax: 512-398-6843
Mailing address:
  • Phone: 512-398-3464
  • Fax: 512-398-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG1943
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: