Provider Demographics
NPI:1659466373
Name:LAWRENCE H WANETICK MD INC
Entity Type:Organization
Organization Name:LAWRENCE H WANETICK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WANETICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-280-0800
Mailing Address - Street 1:1776 YGNACIO VALLEY RD STE 102
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3100
Mailing Address - Country:US
Mailing Address - Phone:925-280-0800
Mailing Address - Fax:925-944-3338
Practice Address - Street 1:1776 YGNACIO VALLEY RD STE 102
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3100
Practice Address - Country:US
Practice Address - Phone:925-280-0800
Practice Address - Fax:925-944-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34947Medicare UPIN
CA00G132010Medicare ID - Type Unspecified