Healthcare Provider Details

I. General information

NPI: 1871685255
Provider Name (Legal Business Name): BRUCE LAWRENCE MD PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 30TH ST 2ND FLOOR
OAKLAND CA
94609-3301
US

IV. Provider business mailing address

445 30TH ST 2ND FLOOR
OAKLAND CA
94609-3301
US

V. Phone/Fax

Practice location:
  • Phone: 510-465-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG24736
License Number StateCA

VIII. Authorized Official

Name: BRUCE P LAWRENCE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-465-2500