Provider Demographics
NPI:1164585972
Name:HENRY, LAWRENCE BURNS (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:BURNS
Last Name:HENRY
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 1:970 MONUMENT ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3800
Mailing Address - Country:US
Mailing Address - Phone:310-454-4213
Mailing Address - Fax:310-454-1199
Practice Address - Street 1:970 MONUMENT ST
Practice Address - Street 2:SUITE 204
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3800
Practice Address - Country:US
Practice Address - Phone:310-454-4213
Practice Address - Fax:310-454-1199
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9685T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT9685TOtherOPTOMETRY LIC. #
CAU32027Medicare UPIN