Basic Information
| Provider Information | |||||||||
| NPI: | 1679559603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDRINE | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3705 N ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984076127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537592134 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11367 BRIDGEPORT WAY SW | ||||||||
| Address2: | SUITE 217 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539856134 | ||||||||
| FaxNumber: | 2539856137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD00022122 | WA | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.