Healthcare Provider Details

I. General information

NPI: 1740200138
Provider Name (Legal Business Name): LAWRENCE DARDICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD 370W
SANTA MONICA CA
90404-2102
US

IV. Provider business mailing address

6029 BRISTOL PKWY 100
CULVER CITY CA
90230-6643
US

V. Phone/Fax

Practice location:
  • Phone: 310-586-9001
  • Fax: 310-586-9051
Mailing address:
  • Phone: 310-417-5901
  • Fax: 310-410-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG48334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: