Basic Information
| Provider Information | |||||||||
| NPI: | 1679555452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOMBERT | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028470000 | ||||||||
| FaxNumber: | 6073247615 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028470000 | ||||||||
| FaxNumber: | 6073247615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | D43914 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 042.0016222 | VT | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | P00894865 | 01 | WV | RAILROAD MEDICARE | OTHER | P00458397 | 01 | MD | RAILROAD MEDICARE | OTHER | 038445300 | 05 | DC | MEDICAID | 3810019575 | 05 | WV | MEDICAID | 5273 | 01 | MD | ELDER HEALTH PROVIDER # | OTHER | P00441743 | 01 | MD | RAILROAD MEDICARE # | OTHER | 213391100 | 05 | MD | MEDICAID | 0001 | 01 | MD | BCBS DC | OTHER | 529810-09 | 01 | MD | BCBS MD | OTHER | 52981008 | 01 | MD | CARE FIRST BCBS PROV. # | OTHER | 6882-0001 | 01 | MD | CAREFIRST BCBS- DC | OTHER |