Provider Demographics
NPI:1770604407
Name:LAKEWOOD INTERNAL MEDICAL GROUP
Entity type:Organization
Organization Name:LAKEWOOD INTERNAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERSHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-633-4117
Mailing Address - Street 1:3650 SOUTH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1502
Mailing Address - Country:US
Mailing Address - Phone:562-633-4117
Mailing Address - Fax:562-633-6560
Practice Address - Street 1:3650 SOUTH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1502
Practice Address - Country:US
Practice Address - Phone:562-633-4117
Practice Address - Fax:562-633-6560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22752261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ70783ZMedicaid
CAZZZ70783ZMedicaid
CAA23230Medicare UPIN