Provider Demographics
NPI:1578625364
Name:LAWRENCE, PATRICK BERWYN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:BERWYN
Last Name:LAWRENCE
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 1:1061 E VERNON AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-3772
Mailing Address - Country:US
Mailing Address - Phone:323-233-9686
Mailing Address - Fax:323-233-0595
Practice Address - Street 1:1061 E VERNON AVE
Practice Address - Street 2:SUITE F
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-3772
Practice Address - Country:US
Practice Address - Phone:323-233-9686
Practice Address - Fax:323-233-0595
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20149207QA0505X, 207R00000X, 207V00000X, 208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA20149OtherLICENSE