Basic Information
| Provider Information | |||||||||
| NPI: | 1508829318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAWRENCE | ||||||||
| FirstName: | IBIYONU | ||||||||
| MiddleName: | OMOWUNMI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 829642 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191829642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664706626 | ||||||||
| FaxNumber: | 4135990470 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 PATERSON ST | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322356968 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 25MA0835900 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | MD439522 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 25MA08359900 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 25MA08359900 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102517277 | 05 | PA | MEDICAID |