Provider Demographics
NPI:1326108325
Name:PUTONG, LAWRENCE (PT)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:
Last Name:PUTONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SERENO DR
Mailing Address - Street 2:KAISER PERMANENTE OCC HEALTH DEPARTMENT
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2441
Mailing Address - Country:US
Mailing Address - Phone:707-651-4408
Mailing Address - Fax:707-651-2955
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:KAISER PERMANENTE OCC HEALTH DEPARTMENT
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-651-4408
Practice Address - Fax:707-651-2955
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist