Provider Demographics
NPI:1770589103
Name:GIPSON, LAWRENCE LARAY (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:LARAY
Last Name:GIPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-0212
Mailing Address - Country:US
Mailing Address - Phone:724-483-8065
Mailing Address - Fax:724-565-5110
Practice Address - Street 1:305 MCKEAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLEROI
Practice Address - State:PA
Practice Address - Zip Code:15022-1416
Practice Address - Country:US
Practice Address - Phone:724-483-8065
Practice Address - Fax:724-565-5110
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020526E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA180012945OtherRAILROAD MEDICARE
PA60198OtherUNISON
PAP019692OtherCHAMPUS
PA1478243OtherUMWA
PA1011634OtherGATEWAY
PA77999OtherAETNA US HEALTH CARE
PA0009070000001Medicaid
PA1011634OtherGATEWAY
PA60198OtherUNISON