# LAWRENCE VIDAVER MD

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1336354356
- **Authorized official:** LOUISE MACY (BILLING MGR)
- **Authorized official phone:** (410) 298-8223

## Contact information

- **Practice address:** 1411 MADISON PARK DR, GLEN BURNIE, MD 21061-5613
- **Practice address phone:** (410) 761-1037
- **Practice address fax:** (410) 298-8225
- **Mailing address:** 2506 LARRYVALE RD, BALTIMORE, MD 21209-3206
- **Mailing address phone:** (410) 764-1116
- **Mailing address fax:** (410) 298-8225

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 025559 | MD | Yes |

## Other

- **Enumeration date:** 05/12/2007
- **Last updated:** 11/20/2007