MEDICARE: DR. LAWRENCE SCOTT MACTAVISH II D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	1715	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	00448339	OTHER	TX	RR MEDICARE
5	P00397523	OTHER	TX	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8W6251	OTHER	TX	BCBS
4	80207X	OTHER	TX	BCBS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104858885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE SCOTT MACTAVISH II D.P.M.

Provider Business Mailing Address
First Line	:	17215 RED OAK DR
Second Line	:	STE 102
City	:	HOUSTON
State	:	TX
Zip	:	77090-2611
Country	:	US
Telephone Number	:	281-444-4114
Fax Number	:	281-453-1269

Provider Business Practice Location Address
First Line	:	17215 RED OAK DR
Second Line	:	STE 102
City	:	HOUSTON
State	:	TX
Zip	:	77090-2611
Country	:	US
Telephone Number	:	281-444-4114
Fax Number	:	281-453-1269

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	02/08/2011

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Directions to “ DR. LAWRENCE SCOTT MACTAVISH II D.P.M.” Practice Location

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