Provider Demographics
NPI:1689650061
Name:WASSER, LAWRENCE J (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:WASSER
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-629-6000
Mailing Address - Fax:502-852-4989
Practice Address - Street 1:231 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1821
Practice Address - Country:US
Practice Address - Phone:502-629-6000
Practice Address - Fax:502-852-4989
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20466207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100463670Medicaid
KY64204662Medicaid
IN100463670Medicaid
C68184Medicare UPIN
KYK056260Medicare PIN