Provider Demographics
NPI:1851456586
Name:MARSHALL, LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28142 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-1248
Mailing Address - Country:US
Mailing Address - Phone:310-832-2020
Mailing Address - Fax:310-832-0342
Practice Address - Street 1:28142 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-1248
Practice Address - Country:US
Practice Address - Phone:310-832-2020
Practice Address - Fax:310-832-0342
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8278T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082780Medicaid
CA210805Medicare UPIN
CAOP8278Medicare ID - Type Unspecified