Provider Demographics
NPI:1417024852
Name:LAWRENCE, BRUCE RAYMOND (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:RAYMOND
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 S EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6202
Mailing Address - Country:US
Mailing Address - Phone:760-757-3070
Mailing Address - Fax:760-757-7139
Practice Address - Street 1:2119 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6202
Practice Address - Country:US
Practice Address - Phone:760-757-3070
Practice Address - Fax:760-757-7139
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1273213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E12730Medicaid
CAE1273Medicare ID - Type Unspecified
CA000E12730Medicaid