Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 036-060418 | IL |
NPI | 1013098920 |
---|---|
Provider Name | Mr. Clyde Harris Lawson |
First Address | Chicago, IL 60620-5322 |
Second Address | Chicago, IL 60620-5322 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2006 |
Last Update Date | 31/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036060418 | (05) | IL |
D14380 | (02) | IL |