Provider Demographics
NPI:1114107802
Name:LAWRENCE G MOCK, O.D.
Entity Type:Organization
Organization Name:LAWRENCE G MOCK, O.D.
Other - Org Name:BROADWAY EYEWORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRANCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:925-930-7484
Mailing Address - Street 1:1389 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-4636
Mailing Address - Country:US
Mailing Address - Phone:925-930-7484
Mailing Address - Fax:925-930-7469
Practice Address - Street 1:1389 N BROADWAY
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4636
Practice Address - Country:US
Practice Address - Phone:925-930-7484
Practice Address - Fax:925-930-7469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055710Medicare PIN