Provider Demographics
NPI:1326166521
Name:MATT, LAWRENCE HARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:HARRY
Last Name:MATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11633 SAN VICENTE BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6512
Mailing Address - Country:US
Mailing Address - Phone:310-451-4779
Mailing Address - Fax:310-393-1665
Practice Address - Street 1:11633 SAN VICENTE BLVD STE 106
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6512
Practice Address - Country:US
Practice Address - Phone:310-451-4779
Practice Address - Fax:310-393-1665
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43801207ND0900X, 207NS0135X, 207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE32655Medicare UPIN
CAW19070Medicare PIN