Healthcare Provider Details

I. General information

NPI: 1164419149
Provider Name (Legal Business Name): LAWRENCE GLEN MOCK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 N BROADWAY
WALNUT CREEK CA
94596-4636
US

IV. Provider business mailing address

1389 N BROADWAY
WALNUT CREEK CA
94596-4636
US

V. Phone/Fax

Practice location:
  • Phone: 925-930-7484
  • Fax: 925-930-7469
Mailing address:
  • Phone: 925-930-7484
  • Fax: 925-930-7469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT5571T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: