Provider Demographics
NPI:1235436122
Name:LAWRENCE, JOHN MARK (LAWRENCE JOHN MARK)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:LAWRENCE JOHN MARK
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:MARK
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11078 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-3232
Mailing Address - Country:US
Mailing Address - Phone:310-476-7901
Mailing Address - Fax:
Practice Address - Street 1:11078 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3232
Practice Address - Country:US
Practice Address - Phone:310-476-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGFE22096174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist