Provider Demographics
NPI:1548274715
Name:MADEWELL, LAWRENCE J (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:MADEWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34876
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1876
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:425-656-4096
Practice Address - Street 1:26458 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038
Practice Address - Country:US
Practice Address - Phone:425-656-5577
Practice Address - Fax:425-656-5595
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00011292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH02666Medicare UPIN
WAG8865734Medicare PIN
WAG8806025Medicare PIN
WA8244899Medicaid
WAG8865733Medicare PIN