MEDICARE: DR. LAWRENCE JOHN WAITE O.D.

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	152W00000X	Optometrist	TUV4209-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OVS71	OTHER	NY	BC&BS

General Provider Information

NPI Number	:	1578561122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE JOHN WAITE O.D.

Provider Business Mailing Address
First Line	:	382 W CHURCH ST
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-2621
Country	:	US
Telephone Number	:	607-733-2694
Fax Number	:	607-733-1139

Provider Business Practice Location Address
First Line	:	382 W CHURCH ST
Second Line	:
City	:	ELMIRA
State	:	NY
Zip	:	14901-2621
Country	:	US
Telephone Number	:	607-733-2694
Fax Number	:	607-733-1139

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	11/06/2007

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