Provider Demographics
NPI:1407016165
Name:LAWRENCE DINENBERG MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:LAWRENCE DINENBERG MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DINENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-450-1212
Mailing Address - Street 1:9834 GENESEE AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1230
Mailing Address - Country:US
Mailing Address - Phone:858-450-1212
Mailing Address - Fax:858-453-9271
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1230
Practice Address - Country:US
Practice Address - Phone:858-450-1212
Practice Address - Fax:858-453-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG25011Medicare PIN