Provider Demographics
NPI:1871685255
Name:BRUCE LAWRENCE MD PROF CORP
Entity Type:Organization
Organization Name:BRUCE LAWRENCE MD PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-465-2500
Mailing Address - Street 1:445 30TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 30TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3301
Practice Address - Country:US
Practice Address - Phone:510-465-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24736207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G247360Medicaid
CAA42364Medicare UPIN
CAA42364Medicare UPIN