Provider Demographics
NPI:1730164492
Name:LAURENCIO, ISAGANI D (MD)
Entity type:Individual
Prefix:
First Name:ISAGANI
Middle Name:D
Last Name:LAURENCIO
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 1:408 KEAN TER
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-3322
Mailing Address - Country:US
Mailing Address - Phone:301-759-2787
Mailing Address - Fax:
Practice Address - Street 1:10701 NEW GEORGES CREEK RD SW
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1457
Practice Address - Country:US
Practice Address - Phone:301-689-3229
Practice Address - Fax:301-689-1129
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD19954208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLU39HU 416653 02OtherCAREFIRST BC BS - HT.CLUB
MD41665301OtherCAREFIRST BC BS
DCE458 0015OtherBLUE CHOICE - HT. CLUB
DCK029 0003OtherBLUE CHOICE DC
WV0050694000Medicaid
DCK029 0003OtherBLUE CHOICE DC
MD672SMedicare PIN