Healthcare Provider Details

I. General information

NPI: 1023067303
Provider Name (Legal Business Name): MARK A LORENZEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301B RICHLAND WEST CIR
WACO TX
76712-7919
US

IV. Provider business mailing address

PO BOX 938
KILLEEN TX
76540-0938
US

V. Phone/Fax

Practice location:
  • Phone: 254-772-2722
  • Fax: 254-772-4075
Mailing address:
  • Phone: 254-634-6999
  • Fax: 254-200-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE8675
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: