Provider Demographics
NPI:1164419149
Name:MOCK, LAWRENCE GLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:GLEN
Last Name:MOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5571T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055710Medicare PIN
T10043Medicare UPIN