Provider Demographics
NPI:1013175751
Name:LAWRENCE L ANDERSON MD PA
Entity type:Organization
Organization Name:LAWRENCE L ANDERSON MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-534-6200
Mailing Address - Street 1:1367 DOMINION PLZ
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1013
Mailing Address - Country:US
Mailing Address - Phone:903-534-6200
Mailing Address - Fax:903-939-0755
Practice Address - Street 1:1367 DOMINION PLZ
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1013
Practice Address - Country:US
Practice Address - Phone:903-534-6200
Practice Address - Fax:903-939-0755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAWRENCE L ANDERSON MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085541301Medicaid
TXCN9571OtherRAILROAD MEDICARE PTAN
TXCN9571OtherRAILROAD MEDICARE PTAN