Provider Demographics
NPI:1437198058
Name:CHESPAK, LAWRENCE W (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:W
Last Name:CHESPAK
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:PO BOX 16699
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-6699
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:18344 CLARK STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-881-9811
Practice Address - Fax:818-881-1638
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG626972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G626970Medicaid
CA00G626970OtherBLUE SHIELD
CAWG62697PMedicare PIN
CAWG62697OMedicare PIN
BG531ZMedicare PIN
CAWA62697DMedicare PIN
CA00G626970OtherBLUE SHIELD
CAP00238978Medicare PIN