Provider Demographics
NPI:1255411104
Name:WANETICK, LAWRENCE (MD FACS)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:WANETICK
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 YGNACIO VALLEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3190
Mailing Address - Country:US
Mailing Address - Phone:925-280-0800
Mailing Address - Fax:925-944-3338
Practice Address - Street 1:1776 YGNACIO VALLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3190
Practice Address - Country:US
Practice Address - Phone:925-280-0800
Practice Address - Fax:925-944-3338
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G132010Medicare ID - Type Unspecified
CAA34947Medicare UPIN