Basic Information
Provider Information
NPI: 1962978205
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LAWTON
FirstName: ETHAN
MiddleName: CHARLES
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1450 S LAPEER RD
Address2:  
City: OXFORD
State: MI
PostalCode: 483716108
CountryCode: US
TelephoneNumber: 2489699932
FaxNumber:  
Practice Location
Address1: 1225 E BIG BEAVER RD
Address2:  
City: TROY
State: MI
PostalCode: 480831905
CountryCode: US
TelephoneNumber: 2485248801
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/14/2018
LastUpdateDate: 10/18/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

ID Information
IDTypeStateIssuerDescription
XYU99305347105MI MEDICAID


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