Healthcare Provider Details

I. General information

NPI: 1265483424
Provider Name (Legal Business Name): THEODORE LAWSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BURMA AVE
GILLETTE WY
82716-3426
US

IV. Provider business mailing address

501 S BURMA AVE
GILLETTE WY
82716-3426
US

V. Phone/Fax

Practice location:
  • Phone: 307-688-1415
  • Fax: 307-688-1420
Mailing address:
  • Phone: 307-688-1415
  • Fax: 307-688-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5598A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: