Provider Demographics
NPI:1023046547
Name:LAWRENCE, TRACY DEBRA (MD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:DEBRA
Last Name:LAWRENCE
Suffix:
Gender:F
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73940207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A739400OtherBLUE SHIELD
CACE1617OtherGROUP RAILROAD MEDICARE
CAP00407895OtherRAILROAD MEDICARE
CAW11675OtherGROUP MEDICARE PIN
CA1356390009OtherGROUP NPI
CAGR0016910OtherGROUP MEDICAID PIN
CA00A739400Medicaid
CA00A739400197OtherCAL OPTIMA
CAWA73940DMedicare PIN
CAGR0016910OtherGROUP MEDICAID PIN
CA00A739400Medicaid