Provider Demographics
NPI:1982662904
Name:CLARK, LAWRENCE ERWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ERWIN
Last Name:CLARK
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 1:7117 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2658
Mailing Address - Country:US
Mailing Address - Phone:951-782-3769
Mailing Address - Fax:
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2658
Practice Address - Country:US
Practice Address - Phone:951-782-3642
Practice Address - Fax:951-784-3266
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG435560207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49388Medicare UPIN
CAOOG435561Medicare PIN