Provider Demographics
NPI:1922252816
Name:LAWRENCE W. CHESPAK, M.D., A PROF CORP
Entity Type:Organization
Organization Name:LAWRENCE W. CHESPAK, M.D., A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHESPAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-400-7785
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93062-0190
Mailing Address - Country:US
Mailing Address - Phone:877-778-4151
Mailing Address - Fax:
Practice Address - Street 1:825 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-1309
Practice Address - Country:US
Practice Address - Phone:877-778-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BG529Medicare PIN