Provider Demographics
NPI:1689852337
Name:LAWRENCE R DARDICK MD PROF CORP
Entity type:Organization
Organization Name:LAWRENCE R DARDICK MD PROF CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DORESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-828-9729
Mailing Address - Street 1:3267 KINGFISHER DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3989
Mailing Address - Country:US
Mailing Address - Phone:775-828-9729
Mailing Address - Fax:775-825-0389
Practice Address - Street 1:3267 KINGFISHER DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3989
Practice Address - Country:US
Practice Address - Phone:775-828-9729
Practice Address - Fax:775-825-0389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV87352085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVE88972Medicare UPIN